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So, hey guys. Um so, you know, this is what we've discussed so far. Uh A to E news G CS, uh survey examinations in initial investigations, further examinations, treatments, management plan. Uh we'll discuss uh but a safe escalation and effective handover. So this one is a quick one. We're just gonna talk about how we develop an effective management plan and liaise with other specialist teams. I'll give you one clinical case. Uh because I think the last session we did free and we kind of, it was quite solid, solidified in terms of what we look for. The rest is up to your knowledge, which I expect you to do in your own time. And the last we'll do a quick Q and A if anyone has any questions. Uh So, you know, three cap, we've last one, we just started, well, we've done a discussed the values examination, the initial treatment and management, done a new score G CS um and the scoring systems in general for serial monitoring. Any changes in consciousness looked at escalation, how to escalate safely and appropriately and looked at handing over um with a format uh sbar format and we've been in the last one specifically, we dealt with treatments uh covering the at bear in mind. Uh When you start work as an F one, even as an F two like myself, we're not the decision makers. It'll be always someone you see you at a reg level usually. And uh if any, if anything's really complex, they will contact the consultant if it's urgent. So, you know, how do we develop a plan? So, so we see a patient, we do an A to e what, what do we do with this information? We spoke, a nurse has come, grabbed us um doing a to e but then we need to act, right? We've talked about treatments and all that stuff, what we need to do for the patient, but we also need to communicate with our team and other teams, right? So the medical team who do we, who do we talk to? We, well, we talk to, well, whoever's in the office really, but as appropriate would have to escalate it. So, you know, if you like this, your senior colleagues are out of the office, they're doing ones that the consultants in a clinic or the reg reg in the clinic and it's just a core trainee. It could be a CST I MT or a G PST. Um um if they're not there, you know, you have your fy two or maybe a clinical fellow uh for support. So for train with, with trainees and, and senior support members, we can call on them if we need another pair of hands to help or another opinion. Uh, but we ultimately need to go to a registrar, like I said, for decision making for investigations or referrals. Um, but outside the medical team, we need to also let our nursing staff know what's going on. So we need to talk to the nurse who's looking after the patient during your assessment. You might want them to be there, but they might have something to do. So they'll say they might say, ok, can you look at him, just have a, have a check? And uh I'm just gonna ii need to do one or two bits and we'll catch up. Usually they'll find you or they'll come back to their patient, but you need to tell them what's going on or what you believe is going on. Um And you know, after that, you should speak to your medical team, but you should let the charge nurse know as well because the charge nurse is in, in charge of the ward. So if they're aware of the situation as well and they're at least aware of the medical teams, discussion and outcome, then I'll keep her happy. Uh And in the loop because for example, if we need uh a patient to be sent, uh if we want a CT scan, we want that the charge nurse will need to be told that because they're the ones who will communicate to the porters, uh people, the people who um, help move the hospital, uh move things around in the hospital are vital for collecting specimens, uh vital for bringing in er, any equipment. And most commonly for uh transferring patients to other areas of the hospital, like radiology. Um, and speaking of which, you know, if we speak to our medical team and the regular consultant then says, oh, it sounds like a job for a certain specialist or they want a scan, then they'll ask you to make that call. And uh you should be able to make that call with some similar SBAR format. Um And you know, and you must know what you are looking for. A red gin or rush can easily say, oh, contact the cardiologist, tell them what happened. Ok. But what's the question? That's a very important thing to ask a senior. Uh And if you know the, if you have, if you in discussion have kind of come to the conclusion yourself, you can, you know, show um that you're thinking ahead for the patient, which is good practice and discuss with your seniors and say, oh, do we need to call cardiologists for this or do we need the surgeons uh because of this or urology because of this, you know, try and think for yourself as well. Don't just let the a senior think for you otherwise she won't grow. Um Right. So you know itu as well, if it's very serious, um it might need itu involvement, obviously, at that point, you know, it might be a reg lead discussion, they might make the call because itu is very particular and they will want to know why the team believes that the patient needs to be escalated to it. What, what specifically requires the patient to be managed by it that your ward can't do. For example, intubation, airway management, multiorgan failure, severe electrolyte imbalances. Uh These things are appropriate for it to get involved with. And if they're full, they might come by just so they can see the patient and give you some advice. But that's something quite senior and serious uh diabetes. You know, you might want, they, if it's a new diagnosis, if, if the patient's coming with a, with a, like a uh hyperglycemic uh state and uh and a coma, then you and you do a blood sugar then and it shows quite high. Uh and they don't have a formal diagnosis then uh it might be worth get speaking to diabetes for a new diagnosis or to come and make a referral for management. Um And you know, there's something I didn't specify in the last two sessions, you have to document, you have to document the assessment, uh the plan and update with the decisions made by seniors and any scans, it's your job to make sure uh the notes are up to date for the medical team um and uh a key tip uh to save time because as an F one, you have to write up discharge letters and that can take a lot of time, especially uh complex patients. So what I tend to do is uh document um any, anything that's happened. So you can get even quickly noting deterioration this date uh evening, you know, uh that can save time because whoever's writing it, it may not be yourself, it might be another f one. It might be another colleague. So whoever's reading that will will see that and actually go back specifically to that date and like time uh for when the deterioration occurred. So they can add that to the discharge letter. Uh It is important uh to add it, say if a patient has come in one once admitted, you know, they were fine, but then they uh went into cardiac arrest. You need to put that on the discharge letter. It's what has kept them in hospital. Um It sounds obvious but some departments are very busy and things might be missed in the discharge letter that that gets caught out later on by the GPS. For example, if you know, you don't document it, the GP might phone in to say sorry, this patient says he was in hospital for this and this, but it's not on the last discharge letter, what's going on. So do proper documenting is important here. Um And if the referring, you know, specialists have stated the patient will be discussed MDT, for example, think cancers multidisciplinary team discussions. So a lot of uh a lot of teams, um medical teams will have an MDT, uh which is led by the senior members of the department to discuss a case and a proposed uh management plan. For example, uh um you know, in general surgery, you might have a, a colorectal MDT. So if there is a, if there's a cancer in the bowel, then there'll be discussions on how to proceed, especially if the patient is quite complex. So if the referring specialist has said that, yeah, we'll add him to the MDT, then you need to add that in the, the uh discharge notes, try and get details of the consultants, the specialist then might say uh we'll book him in for a clinic, outpatient clinic visit. So you might have to add these details in the in the notes. So if you document it on the patient's notes, try and see if you can add that to the discharge letter, especially for any outpatient scans. If, if you know you're in um say uh let's say renal, right as a department and you've managed the patient for a renal abnormality, but they're also complaining of some right upper quadrant pain, um or some other pain in the abdomen. Um then you might make a refer speak to the general surgeons and say, yeah, I got this patient and he does have some of signs, but it's not urgent. He doesn't need to be admitted back into hospital. So we're thinking of an outpatient clinic visit. Uh Some surgical departments will have acute surgical clinics um in Scotland, they, they're termed surgical surgical assessment clinics uh or you know, aes that kind of thing. So they might say, ok, tell him to come on Monday at 9 a.m. to the to this part of the hospital and we'll see him. So then you can add that on the discharge letter too. Documentation is very vital. If you're good at touch typing, then that's a asset to have. And if there's a scan, if if the general surgeons then say, oh can you book a uh can you book a scan for this patient? Uh He will need an ultrasound, abdomen, abdominal ultrasound, then you need to book it. You need to specify that it's an outpatient scan and you need to add that to his notes. This keeps everything everyone in the loop. But you know, developing around your plan, you know, we've done a, we have our thoughts on what it could or or what it could be. We discuss with a senior and you know, rationalize the the the plan react it. We order the scans, we might need to do, we prescribe the medications, we might need to prescribe including fluids, we take blood, we get IV access uh for that um and so on and so on. But then we have other people we need to talk to. So we have to do uh consider do if we need to contact anyone else outside the department and the nursing staff. Uh So let's have a look. Um uh oh, let's go back. Yeah. So liaising with specialist teams. So for this one, if calling another team, then you should prepare an sbar in time. So you've come back to the doctor's room after assessing a patient who you believe needs to be seen by another department specialist, then uh you look back on your notes and get the situ write down sbar. What's the situation? What's the background, what's the assessment responses or any decisions that need to be made? And when speaking to a senior just always ask, what is the question? Uh like I said, so you're able to keep that in mind and that's especially important because you know, if you're calling a specialist, then without a question to ask them, they're gonna say, well, speak to your senior, get a question and call me back because I'm not sure what you want, right? So you need to be, you need to know what you're asking for, especially with radiology. Uh you have to be prepared uh sometimes to give more detail because the radiologist will think, do you want another type of scan? Is this even appropriate? Uh at the time, is the patient? It doesn't sound you might not have stated that the patient is unstable, um et cetera, et cetera. So, you know, when I, when someone tells me your patient is unwell, then what I tend to do is grab one of the C Cowser computer on wheels. Um Just take that with me to see the patient. So I have their notes next to me while I see them, I can see their form more bloods. I can see any scans, any documentation in the past, especially if this is uh an admission that I, I'm not aware of the story. I don't, I'm not aware of. Um And then, you know, at the end of all of this, uh after you liaise with the teams, document what they've uh said and discuss this with your senior team and act on it. Um And they might want some things to be acted before they arrive to make sure that is that it's ordered. So that's basically it, I just wanted to discuss on those two areas very briefly cos a lot of it is experience related. You'll, you'll figure it out and you'll learn it once you start work. So uh just a real quick one. But this one, I just wanted to, I put cases, but actually, I just wanted to do one because I thought we went quite in depth with another one. And if you have any case or specific ones, then you can ask me at the end. So we have a 68 year old male admitted to A&E history of bowels not opening for four days with two days of worsening, intensifying, uh, associated abdominal pain and vomiting. And you're, you're, you're at the F one and you're asked to clerk and assess the patient. Now, we didn't discuss this, um, in terms of clerking, but I just wanted to ask you, uh, so ask you guys like, what, what do you do first? What, um, what, what, what should we do? Um Now obviously we, we clock but, um, the idea here is you want to go in prepared. Um You don't just wanna walk in and find out what's going on only rush when it is an emergency, uh, situation. Uh, because if you just burst in the room and, uh, and start examining and figuring things out that might actually take longer, uh, a lot longer than you think because if the patient's in pain or if the patient can't speak because of the pain or any other reasons, you're not gonna get the answers you want, right? So, with that, what I would do in a professional setting, if the patient is otherwise stable is I would quickly sift through the patient records, see what they have. So all this, all this states or all anyone is telling you, is this the bowels and abdominal pain and vomiting episodes? Ok. What's going on in the background? So, what I usually do is if the patient is otherwise stable. I'll quickly sift through the patient records. See what else they have. What's their background if they got any scans? Um, have they had any past surgeries? What medication are they taking? Um And uh, if any, if any other scans on the system, then can I view the reports to see if there's any known issues? Um So we don't waste time if we find something, then we go through the effort of getting a scan without checking that he's already had one in the past confirming something. Then it won't really help us. It's, it's a bit of a waste of time. Just take a few minutes. You can note them down on the computer or on paper, um whichever way you want to go about it and that way you're prepared to discuss a story. You, you, you're gonna go in knowing roughly what uh the patient has uh in the background, what they're on medication wise. And, you know, it can kind of help you narrow things down or exclude things entirely. I do this because, you know, if they are in pain, like I said, you know, or they're having any underlying anxiety, I don't want to interrogate the patient on their background history. Um, they may get irritated that they're in pain and someone's asking them to tell me their life story. Um And therefore, you know, they might get irritated at the examination or I might, they might miss out details, including medication. Commonly, a lot of patients aren't able to recall exactly the names of their medication. So, it's always very helpful to pull up the list of medication and run through it with uh the patient. Right. So, here's the background. We have an exsmoker atrial fibrillation, uh previous uh laparoscopic hernia repair two years ago. Um, recently he had an uh abdominal ultra ultrasound, an abdominal ultrasound scan, confirming cholelithiasis gallstones and was recently discharged for acute cholecystitis. So, gallbladder in uh inflammation. All right. So what do we do? We've read up, we've got the background stuff. I haven't included medications on purpose, but like not for a particular reason actually, but because it's not relating to the case. But, you know, um what do we do? Well, as I hope, you know, you've learned something from our last couple of sessions. We do an a to a uh we have to assess the patient and examine the patient, right. So, a, you know, patient's talking, it's patent, there's no query about the airway there. Respirators 18 mm, bit higher but not bad. Sats are 96 on air heart rate's 100. Um So it is quite fast with normal BP and CRT less than two seconds. So good perfusion, but a raised heart rate, G CS 15 out 15, there's no changes in consciousness level and everything seems to be working fine. Neurologically. Uh blood sugars are also normal, no exposure. So, temperatures 37.8 which is slightly warmer but not too bad. And it's a distended abdomen with central and right upper, uh, uh, right upper quadrant tenderness. No peritonism. When you listen with your o stethoscope, there's a high pitch bowel sounds with no new hernias. You see the old hernia. Um, it say, let's say it's, um, a femoral, uh, oh, a femoral hernia. No, femoral, uh, inguinal her. Yeah. Sorry. And you see the scar and you notice it that it looks fine, there's no issues there. So, what, what do you do? You know, we see this, we go back to the doctor's room, we have a chat with our reg, right? So I have, you know, a 58 year old man, da da da da. He's coming with this. He's got this story to him. Does anyone know or can anyone tell me what they think is going on? And this is quite crucial, uh, for you guys before you start, it's quite an important surgical emergency and I purposely chose a surgical one, um, because we've been discussing medical ones last week. Ok. And you want me to take a guess? Yes, it is an obstructive picture, isn't it? Ok. So the clue was there. But general surgeons, we query an obstruction with our reg who agrees. And he says, you know, looking back, he, he hasn't passed bowels for a good couple of days. He's been eating normally nothing's passed through and he's got increasing abdominal distension, worsening, pain, frequent vomiting episodes. Uh, so, you know, what do we do for to treat this? I'll leave this here, uh, to give you some, to leave you the important information. I'm looking for a few things, not, uh, one or two, link back to the at treatments. So we have a fast normal breathing. It's still normal. I don't think that requires oxygen at the minute. Now, see, it's also raised that could be in response to the pain. But, um, uh, you know, there's something really going on there. G CS also fine. The temperature is mildly raised. Mm, you have distended abdomen and it's painful, right? So, what, what do, what do we do in a patient who's frequently vomiting without bowels passing? So what goes in seems to come out and at this point, um, the vomiting episodes are fecal in nature. Yeah, fluid replacement. But that's the, that's not the first thing we do. That is like the second thing if anything we do, but I'm not looking for fluid or electrolyte imbalances. We're talking about a patient who is frequently vomiting with bowels not opening. Uh, and what, what is going in is coming up and out. So what do we, what do we put in? What, what do we put in the patient to decompress things down in the gastrointestinal tract? Exactly. We want a gastric tube. Specifically, an NG tube food replacement is important too. So I give you a resource. Absolutely. Do we know what fluids to give? What fluid will we give in this patient? That's a bonus point. But it is very important here. Think of the contents that are coming out. Um, uh, think, think that it's not blood, it's not sputum, it's vomit, it's gastric content. So, what fluids should we, uh, use? Does anyone have a guess? Or? And at all? Cos we, it's kind of cheeky of me cos we just did it last week. I know, but, and I didn't cover fluids, but I just wanna see. Well, it's actually saline. We want, when we're vomiting up a lot, we are losing acid, acid specifically is hydrochloric acid and that's chlorine ions. So we need to replace that. Um, that has an effect on, um, on a, a much smaller scale, but it is important to maintain homeostasis. Uh So we would give um like a quick bag of saline, uh 500 mils or 250 mils depending on the situation. If they, if I had gone unsaid, uh you know, heart rate is 100 and 10 and BP is say 90 then it's quite a, it's a shock picture. And then we might want to give that, uh we'll give that bag of foods like as quick as we can because it's peripherally uh low. Um that's a low circulatory volume. So, yeah, we will give a analgesia but ideally not opioids as first line, no matter how bad the pain is, we want to keep the pain ladder steady. And if you're not aware of the pain ladder, then, uh, look it up. We, we obviously it, it comes with nuance because if someone's screaming in agony and it is valid for a valid reason, there are always, you know, some people might have be sensitive to pain. Some people might have chronic pain and some, it might be fictitious. But, you know, if it's deemed appropriate, then, yeah, you might want something more, more uh more strong. But in this case, we actually want to start off with paracetamol and see how they go unless it's dire. Uh But for a small bowel obstruction, we want to give paracetamol IV form. So, um so because opioids have an effect on peristalsis, it kind of slows gut motility, which we do not want either. It will just make aggravate the situation. And we want antiemetics really, really important to calm everything down. Um From the gastric aspect, we uh want to prescribe some um of any of these on Diron cyclizine or prochlorperazine, that's a buccal form you can have. So if, um, if someone has difficult IV access and you can't get them obviously to eat or, or ingest uh the medication because of the bowel obstruction or nil by mouth, uh, then you can give a buckle uh antiemetic like prochlorperazine. Um And you know, this is kind of the starting point. One thing I me left out, left out uh atrial fibrillation, the patient has atrial fibrillation. When someone is admitted with atrial fibrillation uh to the hospital, usually we use our own anticoagulants because they might be on something stronger on something stronger like Apixaban A doac. Um But because this is a surgical uh inquiry, now we want to keep them on a more easily reversible form of anticoagulants because if the patient needs to go to theater, they can't go to theater with uh anticoagulation in their system or short acting anticoagulation in their system, right? Um With long acting, sorry, we need, we need more of a short acting anticoagulation because if something happens and changes, they'll be taped to theater. But if you touch them, uh they'll just uh hose blood, right? So when someone with atrial fibrillation comes in, we usually stop or hold off prescribing their usual, um, atrial fibrillation medication and we'll start off with whichever the hospital um requires. It's usually clopidogrel. Um, um, and uh uh a kind of low molecular weight heparin. Um, so, yeah, what investigations would you then want to do for this patient? Because we speak to general surgeons and the general surgeons are, can easily turn around and say, yeah, small bowel obstruction. Um, they agree that we need to do IV Reuss food resources. We, they agreed to the NG tube. Absolutely. Um, and they agreed to analgesia and antiemetics. But what, what initial investigations would you expect from a patient like this or primary golden standard investigation? Bye and absolutely, a ct scan more specifically, uh the abdomen, uh an abdomen, pelvis, ct, you know, some places might just say CT abdomen by that point, you're basically already gonna, you're already there. You might as well scan the pelvis too because if there's a transition point or something else you want to see, it might be incidental findings, it's better to just do abdomen and pelvis. So we do a ct abdomen and pelvis. However, after 30 minutes, you know, after you've ordered this, ordered the treatments, ordered the scan and discussed and documented uh with the general surgeons and your seniors nurse comes in and says he's developed a fever. What do we do? What do we do now? Ok. Before any of that, before doing any, obviously, that might be a question we need to look at and that might most likely will be the thing we need to do. But before antibiotics, what do we do if a, if the nurse comes in and says the patient's developing a fever, what do we if we're sitting in the doctor's room do because antibiotics, let me put it into a different way. What uh what antibiotics, there's different antibody protocols for different things. It, you know. Exactly. So, you know, uh antibiotics, there's antibiotics for different things, for pneumonia, for uh uti um for many different things. So, uh so we need like a general protocol antibiotics. So that's why I asked because, you know, when we, when we hear something, we just think, uh, the out we think of what to do and then that's it. But this isn't a simple, you know, M CQ answer right in the real world, you will have to go and see the patient cos if you turn around and s, and ask G reg, oh, he's just about the fever. Uh Should I prescribe some antibiotics? They'll look at you like you're stupid. They will if you, if your first thing isn't to assess the patient. So always, always, always, if something changes reassess the patient, even if it's 30 minutes later, it might be annoying, but you need to do it, you need to see what's going on if it's new. If it's, if it's, if it's something developing with the condition that you've seen them for, always reassess, OK. So we do another 80 airway is still patent respirator has gone up and actually the saturations have come down. However, the chest sounds clear, right? Um So heart rate is 100 and 10, uh BP is 96. So it's definitely taking a hit. Uh CRT is now three seconds and periphery, peripherally cool G CS is now 14 out of 15. So patients are a bit delirious, so to speak because his temperature is 38.5 and you know, you feel the abdomen uh and it, he jumps in pain, uh, when you push around the, the central area, but also the right upper quadrant area. All right, he jumps and says that now this area feels slightly worse than the central abdominal pain. The right upper quadrant pain feels worse. Right. Again, we escalate to general surgeons. But, you know, this has changed. Now, it's possibly a question of, is this a septic acute cholecystitis? You know, if we, if we have read back, you know, we see that on, uh, the, uh, let me get a point out, we, we see that this patient has had an old abdominal scan and recently discharged for acute uh cholecystitis, right? Um So this is again why it's so important to read back because if the patient's not able to tell you, you should be able to look for yourself and find out if there's anything else in the background, you had a previous lap hernia repair two years ago. That's a slightly, you know, if you haven't, if you don't know, then I don't, it's not a problem. I don't expect you to keep this in your mind. But that because I've worked in general surgery, if someone's presenting to you with a small bowel obstruction, and this is experience based. But if someone presents to you with anything abdominally, uh but notably, uh small bowel obstruction, one of the main primary causes of it is actually adhesions in, in the abdomen. So when surgeons operate, they're moving around bowel to access areas. There could be some mild ischemic damage with the instruments or if it's open, you know, where we cut our surgeons, we are removing tissue, cutting tissue to get to where we need to go. And that can leave a lot of adhesions after the tissue heals. When we stitch them back up, adhesions are like are fibrous, they're very tough. Essentially, you think fibrosis in that sense, right? Uh It's not fibrosis, they're adhesions, but essentially, it's scar tissue um that occurs after an operation. And this can be a big core a reason as to why this patient has a sudden small bowel obstruction even two years ago, it can still happen. Uh So I if you go back in the notes, see that they've had a previous surgery, see that it's in the abdomen, they've had a surgery for, uh then you already have an idea of the cause without even seeing the patient. If you have such a story that their bowels are not opening and they have worsened no pain and vomiting. And you see they've had a previous operation and you already have the clues and now they've got right, upper quadrant pain, right, upper quadrant think gallbladder for acute incidences, liver, acutely not a real issue. It's mainly the gallbladder or the large bowel, but mainly it's more commonly the gallbladder. So, you know, they were recently discharged for acute cholecystitis. You know, if, if a patient comes in with write up a quadrant pain and, uh, that you think it's cholecystitis, are they gonna get an operation immediately? No, if you do an abdominal ultrasound and it shows stones in the gallbladder and the otherwise stable news one or zero, then, um, that's it. You know, it's a flare up. It's a, it's an inflammation which will, which will settle, uh, ideally if it doesn't settle. That's another story. If it worsens, then that's another story. But if someone has cholelithiasis, then that's not a reason for admission. If they have acute cholecystitis, it can still not mean a reason for admission. So he might come in, they might have found gallstones and you might have had an episode of acute cholecystitis. But then usually you might get discharged with pain relief and some uh antibiotics um to take and to, you know, reduce risk factors for cer cer cholecystitis. So, reduced fatty food intake and, and the like. Um so, you know, looking back and keeping this in mind, we have already other ideas of other possible things going on with the patient. So, you know, we want to speak to the general surgeons because now this person who has known cit uh gallstones, cholelithiasis might be developing another episode of acute cholecystitis. However, he's displaying a septic picture. So, is this aseptic acute cholecystitis right? Now, the treatments? So we would want uh the protocol antibiotics, we would want a formal set of bloods, which we usually would take anyway on a mission. But, you know, if, if we haven't, then a formal set of bloods by then anyway, 30 minutes in, then we'll do a formal set of bloods including an ABG or VBG for the lactic acid for lactate. And what we need are blood cultures. We need to find the causative agent for titration of antibiotics. We can start off with protocol antibiotics, uh for intra abnormal sepsis. Um And uh and there are protocols on, on uh at the hospital online. Um We're not gonna get to that. But yeah, and you know, oxygen's low. We want OXY. Let's start him on oxygen. You can still, you know, have an NG tube and be given oxygen. You need to supplement them. Uh make sure the fluids I didn't have this, but make sure the fluids are running. If they're not, you might want to correct the rate that they're going in. You might want that fluid going in ASAP um at the highest possible speed because if they've been vomiting all day, they are dry. But if they've now got a septic picture, they are now c the circulatory volume has taken a hit on top of it. So you really need to get some fluids in again, stick with Saline or Heart or Harman's. Uh But in this case, Saline and you want the, you can tell the nurses I want increased monitoring for this patient. Cos things are quickly changing. We do a scan. Uh They urgently take him down to the radiology uh lab because he becomes, say he becomes a bit more stable. Uh, do a CTA P uh Act Abdel vs and it shows a thickened gallbladder with stones and CBD with a small brow obstruction showing an impaction. Uh So he's got a, um, im impacted you if you have a look at, if you Google like impaction CT scans, it, it's quite interesting, you'll see quite clearly like a round circle or BA or like a AAA section of stool which is impacted at the site of the uh the small bowel obstruction. Um And you know, it might, the scan will, may also comment on adhesions um depending on the adhesions and you know how many there are, it can cloud up the scan. So they might make a comment on possible adhesions also present. They would note on the report, the old hernia repair. There might be a mesh, uh a metal mesh to kind of keep the, the, the, the, the, the bowel bowel from popping out again to make another hernia. They might comment and say mesh in place, no problems there. Uh So you ha now it's the main thing here is that there are stones in the common bile duct, the CBD. Um So we have choledochal lithiasis here, right? Um We have now got uh ac uh cholecystitis with a thickened gallbladder, but now some of the stones have gone into the common bile duct and are like obstructing it, um that might be causing this uh pain. So, you know, at this point, you'd want the surgeons to arrive and take over the patient will be then taken to the surgical ward. But the main things here is, you know, the main point I wanted to drive for this session is, you know, when we are asked to assess the patient, things are not always black and white and you need to, it's hard for you guys um currently at university in Bulgaria just because you can't kind of interact with British patients, but you're gonna have to kind of bear this in mind when you come over and start working here. Um It's not so black and white. Um and patients you'll meet all kinds of patients, right? And ideally what I would advise is if it's appropriate, if it's an emergency, you, you manage them and stabilize them and ask questions later, right? But if you have time, if you, if there's a new admission that otherwise stable. Um and in terms of that otherwise stable, when a patient is usually admitted to hospital, a nurse would usually take their observations, get their vital signs and do a new score as a baseline. But you know, if a patient has been admitted and then uses eight, then they will run to the doctor's office to get some help. But if their news is one and two, then, you know, they're fairly stable. And if you hear from now on, if you hear the story of this kind of story of someone with a small bowel obstruction, then, you know, um, at least you can tell the nurse. Yeah. Can you just put an, an NG tube in? And I'll come, I'll read up on him and, and I'll come and see him already. You can start that treatment. You don't have to always assess in the when, when answering interview questions and you know anything else? Yes, you always assess the patient. But in real life, you have to, there's always gonna be some other factors. You have to contend with the business of the, of the department, the work or the jobs list all the tasks that you have to do. So try, you have to be flexible and showing that flexibility is a, is a core, is a key skill. So, you know, the main things I wanted to Hammerer in is, you know, we read up ideally uh on the patient before we go and assess them. So we have, you know, um adequate information. We then examined an A to e and we can start the initial treatments we escalate. And uh well, we referred to the appropriate department for better care, the general surgeons in this case, after speaking to our registrar uh or consultant and you know, when the patient deteriorated, we reassess the situation we can then compare it to a early assessment which we did cos we looked back and kept in mind the background that he had an, a flare up of acute cholecystitis fairly recently with known gallstones and then re escalated and discussed again with the surgeons uh because of these changed, er, these er, altered circumstances. Uh This is a real case that I had to deal with. Um, admittedly not on A&E this was in the general kind of surgery department. I've just altered some details, uh, to give an idea, but the case is the same. I had a patient who Etsy, otherwise I've got on that. I see that. Uh, sorry about that. Yeah. Right. For sepsis, giving IV fluids. We, if a patient comes in with a septic picture we give, um, usually it's bolus, it's a bolus of fluid. It will usually be a bolus of either, you know, saline, but most commonly plasma lights or heartburns with a maintenance bag on top. So, because at the moment you have to bear in mind at the moment. If someone's having a septic picture and they have a BP of 96 systolic, you don't want a long, uh, uh, um, uh, uh, like a bag of maintenance fluid to run at a slower rate or a standard rate for over 24 hours. You want fluid to go in and at the quickest rate possible because they are dry. So their circulatory volume is low or in that sense that they're facing shock. So that's uh so they have hypervolemia at that point because the BP is low and the heart rate is high. So the important thing is trying to replenish that uh uh the volume in the blood of with fluid, so that the BP can stabilize, so that um the heart rate can come down, so that oxygen can be supplied quicker to other parts of the body to fight off an infection. So usually if you have uh a septic patient, you will want to give a, a bolus uh apartments at a, at the quickest rate possible. Say, you know, either depending on the patients. This is the thing when it comes to real world. Uh uh it, it comes a nuance but it can be 250 mL or 500 you infuse that quick rate and then you put on uh a maintenance bag of fluids at a slower rate. So once the quick rush of fluids are finished, you can then put up a, a bag over a longer period of time. Um, and bear in mind, you know, if that first bolus isn't improving, then you need to try another one. So you'll always be reassessing the situation, er, and up and getting updates on that septic patient. But anyway, this was a patient I had uh in general surgery and I wanted to kind of speak on, I want to give you a case where things change because that's something you'll have to understand and experience. You might have a patient. That's absolutely fine one day and, um, a few hours later they are completely different. Depends on the ward you work in, but it really, it really can shock you how things, how quickly things can change. Right. So, we reassessed compared to the earlier, we made the right escalations to general surgery. So, this patient, uh, because he developed septic, acute cholecystitis, the team were quite worried because he has a small bowel obstruction and he's got a septic picture. It might be worth investing, uh, like, er, taking to theater as an emergency case. But ultimately, in the end, we wait, we kind of waited a bit more. We watched them, wait and waited. We started antibiotic therapy and conservative management. And ultimately, the patient did settle, they however did have stones in the common bile duct. So they were booked in, uh, to try and, um, get those stones out of the common bile duct, um, whilst, um, managing the small bowel obstruction. And then after a while, uh, the small bowel obstruction wasn't alleviating. So they decided to take the, uh, patient to theater, uh, to try and address it. So I want to give you a situation because things can change and you'll always be asked, you will be asked in an interview with clinical cases. You know, here's the patient, you do an at E and now all of a sudden you notice the patient becoming breathless, all of a sudden this has happened, that has happened at the start. You need to say, well, I need to reas reassess the patient again. Uh or if, and, and as soon as you notice any signs of severe de um or of deterioration, you can also say I'll also call for help because something is clearly going wrong here. And I think I'll need to escalate appropriately at an early point rather than later. It's up to you, but that's the better way of doing things for an interview, right? So this is the, these are the main points I want to hammer in. It's a very, it's a very quick one really. Uh So that's it, is there any questions that anyone has any other questions? It doesn't have to be related to the series? Uh Exactly. Um If it's, you can ask anything else. Ok. And um I hope, uh you guys found this helpful. Um Ultimately, you guys are in a position where you're coming out, having not experienced anything in the UK. And you're suddenly expected to work at the same level as British medical students coming out, uh which can be quite daunting, don't worry, uh, you'll get there. Um And not everyone, um ironically is as bright as you think. So there are, you know, people who might be a bit slower than others, even British students. So as long as you have, I think this is quite critical when you, before you start work while you're in sixth year. What my advice would be is if you can buy or get the Oxford handbook. Um, where's my Oxford handbook? Uh, let me see, the foundation program. Oxford handbook. If you get this book. Right. And you have a flick through it. It, it talks about a lot of the common issues that you'll face as an F one and how to manage them, uh, as well as, you know, even basic medications that has a pharmacology section, um, prescribing section, even history, uh, and examination, uh, including emergencies and normal value reference ranges. So look it up the Oxford handbook for Found for the foundation program that's F one F two covering. And if you at least read and study the topics in relation to, to, to, uh, to a positive or wherever, er, university, um, if you are able to focus on those areas that the Oxford hand book covers, you can at least feel a bit more reassured that you're, you're actually studying the things which you will see, understand how it is, you know, in, in uni, you can obviously be faced with studying things which you may not ever see. And that's true for every doctor in the world. Right. But if you're quite anxious or you want to be prepared for graduation and starting the UK, my strong advice would be to study um in relation to what you will be most faced with, most likely in the real world. That way, when you come out, you'll at least be covered on the important areas and you can learn and build up your experience from there. If you have any other points or anything else, you wanna ask me um speak to the boys and they can pass it on or, or contact, contact me on uh Instagram, uh wherever Facebook. Um But yeah, hope you enjoyed it. Hope you enjoy the series. Hope you learned from it and hope it makes you better doctors in the end. All right, have a good rest of your evening and I'll speak to you guys later.