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Hello. Um Welcome to your lecture on medical illnesses. My name is Dr Shepard. I am an emergency medicine doctor based in Sheffield. And hopefully I'll be teaching on your wellness special want course in September. So hopefully I need some of you there. So in this lecture, I'll be covering important medical illnesses. So the primary aim is to identify the difference between big sick and little sick patients by being sick and little sick. I mean, big sick is someone who is very unwell and needs to get out of whatever environment you're in by whatever means you have access to a little sick, maybe someone that you can monitor for a bit, see if they get better and hopefully carry on with the expedition. Obviously, this is a big spectrum and the difficult patients will be the ones that fall right in between the two. We'll briefly go over a medical assessment, um abdominal illnesses, cardiorespiratory illnesses, diabetes, and neurological illnesses. And this information will be consolidated through a series of scenarios during the practical week. So you'll be able to put into practice some of your skills that you've hopefully learned here. So this slide is just looking at your overall what you're thinking about when you're looking after a patient um involving the medical assessment, um your observations. So your vital signs, your heart rate, your respiratory rate, your BP, et cetera, and your sort of your examination of your patient and then communication skills after that. So we will ignore the communication skills in a major instance and just focus on the medical assessment and the vital signs for now. So you're starting with the medical assessment. Um So this is the sort of the history that you take from the patient. Um So this patient telling you what their problem is. So initially you ask about what the exact problem is. Um So any they're presenting complaint, so the time course of sort of sort of like a timeline of what's been happening. Um So for example, if they've come in with abdominal pain, when did it start? What were they doing? What does it feel like now sort of their story of what's happening, then you go on to background, this is the patient's background. So any medical history, any medical problems um that you should know about. So, asthma diabetes, they're taking medications and a bit of sort of family history as well. Um And then we talk about on to talking about pain. So pain is really difficult to characterize and it's quite a subjective measure. Um So we like to use something called an acronym called Socrates. Um as a way of being slightly more objective in terms of, um, how you characterize pain and how you ask questions about pain. So, starting with sight is where the pain is exactly. It's often good to ask someone to say, put a finger on where the worst of the pain is. And then you get sort of a specific answer rather than a vague or it's about here in my tummy and then the onset how it's come on. Um So has it come on suddenly or has it come on really gradually? And they've only just noticed it? So it's something they've been noticing on and off for the last few days and the character of the pain, this one's quite difficult. Um But is it sharp, is it dull, is it like achy pain? Is it burning pain, that kind of thing? And radiation means that the pain can sort of be mainly located in one place but feel like it's spreading to a different area of the body associations that associated features. So such as vomiting, shortness of breath, lack of appetite, temperatures, that kind of thing. And then the time course, so this is sort of over the course of the pain. And how is it acting? Is it getting worse? Is it getting better? Is it coming and going at certain periods of time and exacerbating relieving factors? So what exactly makes it worse or better? So, is that a certain position makes it worse or better eating make it worse or better. Does exercise make it worse or better? Then severity again, this is quite, quite a subjective measure, but it is a good way to measure progress within the same patient. So if someone says it's a six out of 10 to start with and then it progresses to an eight out of 10, you know, it's getting worse. But if you give them some pain relief and it goes to four, then, you know, it's getting better. Um, and then carrying on with our medical assessment. So input output. So eating and drinking, weighing and pulling classic questions important to know. Um, and then just what drugs and allergies. So any medications, they're taking any allergies that they might have, especially ones, um, that cause anaphylactic response and then what's important, but often overlooked in terms of medical assessment is what we call ice. So ideas concerns expectations. Patients themselves often have a good idea of what's going on. Either they've experienced the symptoms before or they've done a bit of Googling or, or whatever. So ideas concerns expectations is what they think it might be what in particular they're concerned about. So they might not tell you. But if you find out what they're concerned about, you might be able to either think, oh, that's a valid concern or? Oh, ok. Let me tell you why this isn't a concern and expectation. So what they're expecting what they're wanting out of coming to the medic for help? Are they wanting you to say no, you can't carry on with your expedition, get me out of here or are they wanting help to be able to carry on with the expedition? Then we'll move on to vital signs, which is your examination? Um So as you'll be taught in sort of first aid courses is the doctor ABCD E OK. So that's danger and response. Firstly, as the doctor, it's not on here but um danger and response. So, is it a safe environment to approach? Shout at the patient's name. Are they awake? Um AIC. So, and then we go on to the ABCD. So airway, are they talking to you? Are they breathing their airways open? And then in terms of breathing? So do they look like they're breathing hard or do they look like breathing easy and then just cast in your respiratory rate? It's a good idea to do this while you're sort of doing something else so that the patient isn't conscious of their breathing, then moving on to circulation. Um I'm sorry, under breathing, you can use a, a SATS probe as well just to measure the oxygen saturations if that's something you've got to hand circulation. Um So measuring their pulse, um if you know how to check a pulse, sort of either on their wrist or in their neck, um and then cap refill time as well, which is something that we will go through in, um, in person. Um, but it's essentially a sign of their skin perfusion. Um, so is the blood going to all the parts of their body, including the skin, which usually means they've got a good enough BP if they've got, um, blood going to their skin as well. Um, and then just sort of in this section looking at the overall sort of color of the patient, sort of like temperature of the patient. Are their fingers, are the hands and fingers cold? Are they warm? Do they look gray or do they look nice and pink and then disability? So this is sort of, are they responsive and we'll go through, um, the sort of a, a po um, response, uh, response grading, um, and looking at the pupils and also thinking about glucose and blood sugar, we say d is don't ever forget glucose, um, exposure. Um, for e so their temperature, um, you don't necessarily need a formal temperature, but are they going to be, do they feel cold or do they feel hot? Um, and then having a look over their body for any wounds, any rashes? But after you've done that, you do need to keep them warm afterwards after you've done all this, this is when it comes in, you're documenting and your decision making and whether you think it's big sick, little sick, which is what we'll go through afterwards. And I've spoken about a bit about big sick versus little sick. Um So what do I mean by big sick? So this is someone who needs to be essentially evacuated immediately. Um This is the unwell person that you don't want to miss and you want to recognize and that's sort of the, the aim of today really is to be able to, um, think about what someone who needs to be evacuated immediately looks like and, and what they might be presenting with. Um So in terms of their vital signs, um so anyone with sort of heart rate above 100 and 20 a respiratory rate of about above 24 a temperature above 38 5. So if these are sort of consistent, um and they're done correctly, um then they're quite worrying signs and that's something that you should think about evacuating. Um So taking into account the heart rate. So, um just thinking about when you're actually measuring someone's heart rate, are you measuring it as soon as they've walked up a big hill, I think a heavy pack or have they been sat down resting for half an hour or so before you've taken that heart rate? If they have been resting and it's this high, then yeah, that is something to worry about. Um But make sure you're taking sort of an accurate resting heart rate and in terms of respiratory rate. So, yes, respiratory rate above 24 this might be slightly more normal about altitude. Um So just make sure you take that into consideration, but it's more, do they look really breathless? Um, so is this someone who's really working hard to breathe? So patients are working really hard to breathe often, be in sort of a tripod position so be sat up over their knees, bracing themselves with their hands to try and use as many muscles as possible to expand their chest. And does it look like, are there noisy breathing? Are they using loads of muscles? Are their face looking sort of red and from the effort of breathing? So that's something to worry about and then a high temperature as well. So, um, so you can get high temperatures with sort of viral infections and that might be something that you get in your camp. Um, but you need to think about bacterial infections and sepsis as well. So consistently high temperature with someone who's unwell is something you need to think about and then just a sort of a general appearance of the patient, which arguably is slightly more important. So, do they look gray clammy, sweaty? Have you got sunken eyes? Have they got really dry lips and tongue? So that's a good sign of dehydration. They unable to take in any food or fluid. If someone's unable to take in any food or fluid, even if they haven't got sort of a severe medical problem, they're not going to be able to do very well on an expedition. They probably do need to get out of there. Severe pain. Understandably, they're not going to be able to continue and you need to get out of there and you need to figure out what's the cause and any reduced conscious level. So, uh, if they are confused when they're not normally confused and if they are drowsy, when they're not normal, shouldn't be drowsy. That is something to worry about. And that's something that should be evacuated and something we'd put under the big sick category. And so what's some scenarios running through the presentation and all basin sort of the same um expedition group? So you're on a summer eight day hiking climbing expedition in Iceland in a remote part of Iceland um with a group of 18 people, um sort of young adult boys and girls and four leaders as well. Um You two day hike away from the forest road. So that will be the nearest car access point. Um And it is due for a bit of bad weather in a couple of days as well. So we'll start with abdominal illnesses. So caring about the scenario is one of the girls comes into your tent at 1 a.m. and says her 10 buddy, 17 year old girl has severe abdominal pain. So what is your course of action? It take a little time to think about um how you do your medical assessment um And what you might be worried about in this patient. So, I've tried to put some of this stuff together on sort of an easy cheat sheet slide. It's quite a lot of writing for this powerpoint. Um But hopefully it's a slide that you'll be able to look back on in the future if you just need a little sort of profiting about what you need to do for each of these um presentations, but I'll go through each of the sections um a bit slower. Um So firstly on the um assessment of abdominal pain. Um So we're going back to that medical assessment you talked about before. So the timeline of what's happened when it's happened, characterizing a pain. So using that Socrates and then associated symptoms, so specifically would be, it would be some vomiting and diarrhea and then really important with the Donald's illnesses, the eating and drinking, peeing and pooing questions um for females, you'll know when their last period was any chance of pregnancy and maybe a bit about their sexual history as well. Um Your ideas concerns expectations and then their medical past medical history and they should include operations as well, um especially on the operations of the tummy. And then you're going on to the assessment of their vital size and appearance like we spoke about before. Um So a quick look at sort of the causes of abdominal pain. So you don't need to know this exactly because illnesses don't follow the textbook themselves. Um It's sort of a, a rough guide as different pathologies are more likely to cause pain in different areas of the tummy. And so this can be helpful. Um And it's also helpful to know the type of pain that they're experiencing as well. So what I mean by colicky is sort of coming and going, um so it be sort of a low level um, initial pain and then you have sort of sharpness of pain within that low level pain. Um And this tends to occur when something is sort of blocking a tube or the body is squeezing against the blockage. So, hence, stones, constipation, um, menstrual cramps are really common. Um And most women will know what their normal feels like. So if it feels different from the normal and then this is quite a significant bit of history together. Um And all of these pathologies are sort of on a spectrum of severity. The actual diagnosis doesn't matter, it's just sort of there to guide you. And if they see you unwell, they need to go to the hospital. This is sort of a occurring theme throughout this presentation. We're not trying to train you to get the correct diagnosis. Um We're just trying to train you to spot what is someone who is unwell. Um And what is someone who is, well, any of these things can either be really severe or can be quite benign. Um And that's sort of the scale that you need to be looking at not sort of accurately diagnosing the patient. And so just go through some generic management um for abdominal pain. Um So, firstly, pain relief. Um so whatever the patient is carrying or you're carrying in your medical kit, in terms of pain relief is paracetamol, Ibuprofen might sort of upset tummy a little bit, especially if it sounds like a reflux or a gastritis. And um if you're carrying codeine, then possibly codeine could be an option. Just be aware that that will make constipation worse. Um Ors or oral rehydration solutions, that's diary or the cheap version. Um So if the patient can tolerate this, um and they're otherwise not really eating or drinking much, there's gonna be something which can sort of help them get over the edge and might allow them to stay on the expedition. Um And then sort of more consider what the causes could be of the abdominal pain. Um So if it's constipation, they can try some laxatives and if it feels like a reflux, you try some Gaviscon or whatever the off brand one is. Um, if it feels like a uti and they're well, um, give you some antibiotics, I've not specified which antibiotics because the likelihood is that you'll be carrying a broad spectrum antibiotic to cover a range of illnesses. Um And that also depends on availability and what sort of the allergy profile of the group might be. Um, you probably wouldn't carry a specific antibiotic for urinary tract infections, which is what we would normally give. Um, at home. I think important here with abdominal pain is a lot of the serious causes that we spoke about earlier. It's very difficult to assess and manage these in the world in the setting and they need a full assessment and surgical treatment for them. And often in, in A&E we can't fully assess a lot of abdominal pains without sort of getting some sort of scan bloods, that kind of thing, which you don't have access to in the world and environment. And we're not expecting you to be able to make those sorts of judgments. Um So if someone do, you do think someone is unwell, then they are going to need to have to be evacuated for a formal assessment. Let's have a look at um big and little sick in terms of abdominal pain. Um So you've got sort of your parameters as we discussed earlier. So your temperature, your heart rate and your spiritual rate. These are sort of a guide to highlight if someone is unwell and should be used in context. So a patient doesn't need to hit all three of these to get, give them the big sick category. Um If anyone is high, she just probably just think that something a little bit more serious is going on. Um So severe pain and inability to tolerate food or fluid if there's any possibility of pregnancy. Um This is particularly important um as of early pregnancies could be, can be ectopic and can cause severe abdominal pain in young, um, in young adults and sort of your general appearance and gut feeling. It is difficult if you're not seeing many patients. Um, but if the patient themselves would go and see a doctor or go to A&E if they were at home, then they probably need to, in this case as well. And just important to notice is monitor and review. You can change your mind as the illness progresses. Um your your decision isn't something that you've got to stick with. So going back to my initial scenario with the 17 year old girl. Uh so she described her pain starting this morning as umbe like also. So around the belly button and now it's the right iliac fossa, which is the right, um the right lower quadrant of the abdomen. Um a sharp pain that's worse on movements. Nine out of 10 severity is getting worse. She hasn't had any vomiting. Um She had one episode of loose stool. She doesn't really fancy eating or drinking. Her last period was two weeks ago. In terms of her vital signs, her heart rate is 100 and two. Her respiratory rate is 24. Her temperature is 38.1. She looks pretty sweaty and breathless. Um So what's what might be going through your head here? Um Firstly, a stab of sort of possible diagnoses. Um and also is this patient? Well, or is she unwell? So I'd say this patient is probably fairly unwell with vital signs, looking sweaty clammy, um, not eating and drinking, um, high temperature and severe worsening pain. Um, what I'd be worried about in a patient like this is an appendicitis, um, possibly an ectopic pregnancy in a young girl, although her period was recent. So that makes it less likely. And she could also have sort of uh gallstones, gallbladder, kidney stones, uh urine infection, anything along those lines. Um But in any case, she seems quite unwell and we need to get out of there. Your next step is then thinking about how you get someone out of there who can help you, how do you make contact with them and then sort of documenting all your thought process. We won't go into all of that because that will be in another lecture. Next thing we'll look at is diarrhea and vomiting. Um Another favorite. Um So again, this is our sort of little cheat sheet that I've made, but we'll go into each section a bit more, um in detail. So your assessment, so similar to your abdominal pain assessment. So a timeline. What's happened when and quite um importantly, with diarrhea and vomiting is, is it happening to everyone else? Um So you're thinking of is it an infectious cause? So your frequency of diarrhea and vomiting and the vomiting 20 times a day if they've vomited twice and then blood, how much and what color vomiting blood is, um, can be quite scary. Um, but small streaks of, of bright red blood after someone's been vomiting a lot can be quite common. And this is just sort of due to some micro tears in, um, the esophagus. But I'd be really concerned if they're vomiting lots of fresh or digestive blood, digestive blood and digestive blood looks like coffee grounds. Um, and then any associated symptoms. Have you got any pain? Um And you have diarrhea, vomiting any temperatures as well, eating, drinking being pooing last period. And then your past medical history, your vital signs and your appear I have add it on here. Good old Bristol stool chart. So this is a good way of documenting and having a more objective assessment of if someone's outlet and just a quick look at the causes of diarrhea and vomiting. Um So gastroenteritis, food poisoning, heat stroke, very common causes on sort of expeditions and cooking camp food and things if you want to worry a bit more about sort of pancreatitis, head injury, um, bowel obstruction, diverticulitis, appendicitis, many, many causes of diarrhea and vomiting. But as I said before, with abdominal pain, it's not really the exact cause which matters. It's sort of trying to recognize if someone was unwell or not, the general management, diarrhea and vomiting, oral rehydration solution. And again, it's, that is great if someone could keep it down. Um So lose a lot of fluid, a lot of salt. Um and thinking about the wider camp hygiene. So if especially if you think this might be an infectious cause. Um So making sure the camper washing their hands properly, cooking food properly and isolating the uh one infectious individual. The last thing you want is an entire camp of di and vomiting, um monitoring their fluid intake and their urine output. Um Just keeping these documents on the chart may be really helpful to see trends and think about the underlying cause. Think about some pain relief, um anti sickness, if you're happy administering it or the patient themselves has it. Um And then for diarrhea, considering the perides, so Imodium, um it's only really for mild to moderate symptoms and if they're otherwise well in themselves, um you wouldn't want to do this for someone who's quite unwell with diarrhea. Um It can have some severe consequences. Um sort of worsening the illness, severe constipation and even heart arrhythmias. Um So just use it at the minimum required dose to aid continuation of the expedition. Um Antibiotics are only considered the most um severe cause of dysentery, which is blood and diarrhea. And that usually means that they should require a full evaluation, big sick, little sick for diarrhea, vomiting as before fevers, high heart rate, high respiratory rate, um similar a severe pain if they're unable to tolerate food or fluids despite sort of the period of monitoring and trying some plain stuff, um and possibly some sickness, that kind of thing. And if they're still not able to keep stuff down and that's worrying you sort of your general appearance and the gut feeling, gut feeling as well. And as before you can monitor, um if you're unsure and you can change your mind as the illness progresses. So next, it will be uh cardiac and respiratory illnesses. Um So back to our scenarios. Um So during lunch break, one of the leaders, one of the adults comes and complains of sudden onset shortness of breath. How are you going to um assess this? Um What are you considering your history? What are you considering your examination? A lot of words on this slide but just as a little Chee Chee for you and go through it slowly. Um So assessment of shortness of breath um characterizing. Um what happened when it happened, how it happened, characterizing it? So, worse, rest worse while walking, worse while lying down any associated symptoms of pain. So in that case, you take a pain history as well. Um cough fevers, leg swelling, wheeze sputum. Um the usual eat, drink poo pooing and in the past medical history and drugs, allergies, heart disease, asthma, that kind of thing. And are they a smoker? Mm in terms of examining them? So if they've got blue lips, have they got noisy breathing, are they using their arms to breathe? Um are they symmetrically breathing, sort of the chest rising on equal sides. And this will practice in the practical week. I've just got a few, couple of clips of, um, Stridor and these and that will hopefully play. Mhm. Mhm. So, that's Stridor. That is a, um, sound that makes early obstruction if there's any leakage in your can be sort of pending sound of, sort of severe respiratory problems and death. So, recognize that sounds. Um, and that's, that's the one who's big sick and needs to get out of there quickly. And then this is a wheeze. So that's a sound that is made um, on expiration and um, suggests sort of swelling and obstruction of your lower airways. So typically this is the asthma or COPD. I just think about some of the causes of shortness of breath as well. So, asthma, um, I'd like you to know if they have asthma or not carry some inhalers, um, and pneumonia. So it will be a cough temperature if your altitude is worth considering HPE which is high altitude pulmonary edema. This patient is very unwell, they'll be very short of breath, it sort of frothy white sputum as well. Um, pulmonary embolism. So this tends to be a sudden onset and breathlessness with a sharp pain. Um, and this is quite severe as blood clot in the lungs. Um, anaphylaxis. So if they have known to have allergies to any drugs, medications, bee stings, water, things, that kind of thing um and this seems to be treated very properly with adrenaline and they're evacuated out of there. Um The patient themselves, if they're known to have anaphylaxis should be carrying an EpiPen. Um So make sure that you know how to use it. I believe there is a recovery on thelaxis. Um anxiety don't jump to this, but this can be a cause of breathlessness um with um sort of health, um health associates with anxiety um can cause the symptoms of breathlessness. Um heart attack tends to be associated with chest pain. The pneumothorax is a popped lung. Um This could be a sudden onset tends to happen with pain. They be quite breathless and they have an asymmetrical um chest expansion. Um musculoskeletal pain can make you feel breathless and sort of viral problems as well. So, viral infections like COVID, um this all tends to occur come with sort of headaches, muscle aches, sore throats, that kind of thing. And just thinking about some of the management of shortness of breath, um someone's really breathless, putting them sort of a half sitting position. So sat upright, knees, bent up and they're sort of crouching forwards, um bend over forwards can really help um reassuring them um helping them calm down. Um and talking to them is helpful and then just mainly considering the causes. So it's the anaphylaxis, they need the EpiPen, they need to be evacuated asthma. Um There is a, a spectrum of severity with asthma. Um, it can be that it can be managed acutely with sort of this salbutamol inhaler, which is the blue one. Um, this should be done through a spacer and tamp puffs. Um, if they have not bought their spacer with them on the expedition, this can be fashioned with a water puzzle just like in the picture and that can make an effective spacer. It needs to be done with a spacer because that creates the best delivery of the drug to the lungs. Um If they're a little bit more severe, they could try a five day course of steroids. Um But if they're still wheezy after a couple of attempts of the Subbu inhaler, they need to be um evacuated and they need to seek medical proper for proper medical attention. Um pneumonia, um some sort of infection um could be sure you some antibiotics and maybe some steroids if you also have asthma and COPD. Um and hape so high as you call me edema that they need you to send uh that the only real treatment is to send and then your big sick, little sick. So your temperature, your heart rate, your respiratory rate, severe chest pain, any history of cardiac disease. Um If they're looking gray sweaty and if the respiratory rate is slowing down because of the effort, that's a war sign, any Stridor, which is the noise we heard earlier. Um and just a gentle appearance and gut feeling as before. So in this scenario, um the leader had been feeling off for a couple of days, dry cough and some temperatures today. He's been a bit wheezy and struggling to breathe. He took a couple of inhalers but they didn't help. So he's got past medical history of asthma. He's got a heart rate of 100 and five at 24 temperature and sat. So. Ok. Ok. Um So what are the things that might be worrying you with this? Some of the questions I'd want to ask are how he was taking his inhaler. Um So maybe trying it with a spacer. Um And how much have you taken recently? Um, a heart rate of 100 and five at rest, um may be concerning, however, he's taking a lot of his salbutamol that can bring your heart rate up. Um So that alone in a well patient would, would be ok. And so these, so that's before these are sort of decisions you have to think about with each of your patients. So, moving on to chest pain, um we'll look at your chest pain assessment. Um So I'm sorry, this is quite repetitive. Um But they do tend to follow the same structure. Um So your timeline in characterizing the pain is going through your Socrates um pain history again. So, is it worse at rest? Is it worse, walking, lying down, breathing in and then any associated symptoms or shortness of breath feeling sweaty, nausea, fevers, um, any fainting, um, or lightheadedness, any palpitations and then you past medical history, importantly, your heart disease, um, and possibly any family history of any certain heart heart disease, especially at a young age. Um, it causes, um, so similar to shortness of breath. So you've got your pneumonia, your pulmonary embolism, anxiety reflux, um, can cause chest pain, sort of at the lower, um, center of your chest. Um, things to worry about heart attack and angina which we'll go through um in a minute. Um your pneumothorax as before. So, lung can also cause chest pain, musculoskeletal pain, um which is your, your ribs and your muscles and your chest and then sort of viral infections as well can cause chest. So just a quick look at what angina was versus heart attack with sort of a ever increasing um aged population. Um More people with significant medical histories are going on expeditions. Um and heart attack is a common cause of death in sort of fairly fit, but maybe older adults. So, Angina is a narrowing of the coronary arteries, which is the arteries that supply the heart muscle. Um when you get angina, your oxygen demand of the heart muscle is bigger than the supply and that causes the central um crushing chest pain. Um but that's relieved with rest when the supply with the, when the oxygen demand of the heart decreases tends to happen at a predictable effort level. And it's managed with a GTN spray which a patient would normally carry themselves. Um, and this needs evacuating if it's worse than the patient is normal. Although I would be questioning why someone with, um, Angina regular angina is sort of doing it physically exerting as position. And, um, so a heart attack in comparison is a blockage of the coronary arteries. So there's no oxygen supply to that heart muscle. Um, so it's a similar kind of pain. It's a central question. Chest pain can radiate towards the left side and it doesn't go away. Um With rest, uh women diabetics, the pain might be a bit different. So, um, don't sort of go based off that classic history. If they look unwell and in pain, then um that may be it, they tend to be quite breathless, clammy, nausea, sweaty, great and they look unwell and this needs to manage with um sort of 300 mg of aspirin, which can be chewed because that gets into your pore faster. Um A GTN spray and this needs evacuating immediately. It's a matter of chest pain, that half sitting position that we have for breathlessness is um also helpful for chest pain, again, reassurance, pain relief. Um And then considering the causes. So as I said, a, a GTM with angina heart attacks, um and they need evacuating and um pneumonia can be managed with antibiotics. Um if they will enough to continue with the issue and then you big sick sick um for your chest pain. Um So although chest pain can have some really serious causes and not have chest pain needs to be evacuated immediately. Um Looking at the heart rate, respiratory rate, um if they have severe central chest pain, any history, history of cardiac disease, if they look gray and sweaty, um they need to be evacuated. Um And again, just your gen their general appearance feeling really. Um, So you diabetes. Um, so this is something that you come across quite often. Um with often lots of young fit people having type one diabetes. Um I um so we'll go through this a bit slower. Um, so diabetes is type one diabetes, type two diabetes. Um So type one diabetes, um, usually comes on at younger ages when your immune system attacks insulin producing cells. Um So these patients um are managed solely with insulin. This is either a, so it is an injection into your skin. Um, so it's a long acting um insulin twice a day with some short acting insulin when they eat. Also I managed with a pump, um which gives a continuous infusion of insulin. Um Type two diabetes tends to be later onset um where the cells become resistant to insulin. And this is usually due to a consistent high sugar intake over many years. And so this can be managed um sort of the spectrum of um methods. So, an issue with diet and tablets and then insulin as a last resort, um, type one, diabetics are more like to have diabetic emergencies as their bodies completely. Just insulin on expeditions. They should be able to manage their own insulin. Um, so their, um, carb counting and their sick tables. They should think about the storage of insulin, um, and their emergency medications and they should have sugar and ketone testing kits with them. Um, some considerations for expeditions is needing a GP letter to fly with needles, um, having a sharp spin, um, some spare medications in their hand luggage in case the luggage gets lost. Um, thinking about the dose adjustments for activity levels and their diet and making sure they take lots of snacks and stay hydrated. Um, so we'll first look at low blood sugar. Um, so this can, um, present with patients sort of looking very pale sweaty, confused, they can have a reduced conscious level and not extreme seizures at the extreme. So it's defined by any issue that's less than four. the type one diabetics will tend to know will be hypo aware. And so we'll know when the blood sugar is low and that can be, uh, can be at various levels. So it tends to be caused by if they are taking insulin, um, and have too much for their, um, oral intake or if they take an oral hypoglycemic medication is the type two diabetics and Gliclazide is one of those common medications that they take and it's normally combined with sort of a reduced food intake or increased activity level um alongside the too high insulin um or hypoglycemic medication, the management of low blood sugar. Um So if they are awaken with it, um a sugary drink, um just make sure it's not a diet drink, glucose tablets or gel and jelly babies as well. And then that also makes sure they have a slow release carb. Um So for example, bread, toast, if they have a low conscious level and you can get Gluco gel, which should be in their emergency medication kit and it's at the top here. Um and this can be rubbed into their gums and then I MS intramuscular Glucagon um is another medication that type one diuretics can have, this can only be used once it has an effect. This medication here, make sure you retest their blood sugars after 10 to 15 minutes and you repeat this up to three times um before thinking about going fresh help. Um low blood sugar, um is a more serious and sort of a more um pressing emergency than high blood sugar in the short term. So, a transient, high blood sugar if otherwise well doesn't need urgent care and they should be able to adjust the insulin dosing to see other ones and the sort of the feeling of the Expedition, it's only sort of an emergency if they are unwell with it. Um and going to something called diabetic ketoacidosis is defined by the blood sugars being 811 and the ketones being over three. Um this can be caused by sort of illnesses. So, vomiting, diarrhea infection and reduce of not taking that insulin because of these illnesses. Um they need to be managed with fluids are tolerated. Um They're normal insulin doses and these patients need to be evacuated. Um So you got sick. So again, your heart rate and respiratory rate, if they have a reduced conscious level or they're unable tolerate food or fluid, um they will need um medical treatment to be able to manage their diabetes. Um So if they are in DKA, so that means they're very unwell with high sugar and ketone levels, these patients need to be evacuated and if they have hypoglycemia that's not responded after three rounds um or they continue to go back being into hypoglycemia, these patients also need to be evacuated. Yeah, final topic, headaches and neurological illnesses. It's a little scenario to think about what sort of things that might pop up. Um So one of the boys in the group comes to 10 at 6 a.m. saying his friend woken up with a really bad headache, he looks unwell and his temperature of 37.8. So what's your course of action? How are you gonna manage this? Um So it's overall again, your um your headache assessment, we'll go through this a bit slower. Um So your assessment is the same as they've always, they have been for the others really. Um, but just to, to the point home. So your time now what's happened when characterizing the pain with your Socrates, um, and specifically sort of the timing of the pain? And is it worse with light with sound, that kind of thing, any associated symptoms? So specifically, any nausea, any visual changes, any temperatures past medical history, especially sort of the headache history, this is a fairly normal headache for them or not. Um Your red flags um for headaches will be sort of severe temperature. Um a stiff neck, um photophobia, seizures, speech changes, limb weakness, confusion, collapse. I've said seizures again. Um So when we talk about a stiff neck, um it's someone who will not move their head from side to side. Um if you're talking to someone and they're sort of moving the head around and looking up and down and they've not got a stiff neck and also photophobia. A lot of people don't like light. Um but you can shine a light in their eye if you can't shine a light in their eye. Um because they're really recoiling from it, then that is a photophobia um to look at some of the causes for headaches. Um So, so sort of primary headaches um which are just, just headaches are not caused by anything else. Um So a tension type headache, which a lot of people will get and they will know what their normal headache is and this is likely to be a tension type headache or migraine. So some people can be susceptible to migraines and they will know what their normal migraine feels like and how they manage it. Um sometimes can just mean lying down in a dark quiet room for a while, which may actually be quite hard on this position to find that viral illnesses can cause headache, head injuries, um eye pain, um sinusitis, um meningitis, encephalitis. So, these patients are unwell. Um This is what you're sort of worried about. One of these you worry about with headaches and they tend to nausea, vomiting, neck stiffness or rash and it's just non blanching, rash is what we talk about. And so if you press a sort of a, a clear piece of glass and into the rash, it doesn't go away, they don't have to have the rash. Um They can still have meningitis without the rash. Um but it is just one of the um associated symptoms and sort of more severe and intracranial hemorrhage. So this is a sudden onset of severe headache, um associated with neurological changes as well as a limb weakness, speech and neck stiffness. And if your altitude, just considering acute mountain sickness and high altitude cerebral opathy. Um so these patients will be, especially the has patients will be very unwell, they'll be confused. Um They'll be wobbly and vomiting and the management of the headaches Um, so it sort of someone's standard headache and that is normal for them. Um, so pain relief, hydration, fuel rest and then just thinking about the causes of headaches. So suspected meningitis encephalitis if you're carrying an antibiotic with you. Um, so if an intramuscular um Benen or cefTRIAXone as a first line for suspected meningitis or cephalitis, and those patients need to be evacuated, migraines. As I said, a dark room if possible. And migraine sufferers often carry their own rescue medications, which can be a trip which may help and then he sickness and hace. So the main forms, main stay of treatment is descent um to improve this, um A MS can be managed with acetic, but if they've progressed to hace, um they will need dexamethasone to reduce brain swelling and you're big sick, let's sick with headaches. So again, you've got your vital signs at the top. Um But very sudden onset headache, like someone has whacked you on the head with a baseball bat that is a sign of intracranial hemorrhage and that needs to be evacuated and they need to scan of the head, any limb weakness, any speech change, um any facial droop, any confusion, collapse, seizures, fever, stiff, neck, photophobia, and then again, your general appearance and gut feeling. If they'd be going to hospital anyway, they should probably go to hospital in this case. And it's looking at transient loss of consciousness. So sort of essentially a faint really Um So your assessment? Um so this assessment, oh, let me on this side, the assessment, um this assessment is assuming they are not still unconscious otherwise it isn't transient. And uh your assessment should be in the form of doctor ABCD E if that is the case. So if they have had a transient loss of consciousness and so are now um awake. Um So again, your timeline and then what you want to ask is immediately before during and after how they felt. So did they feel dizzy, lightheaded, have any visual symptoms before um during, did they lower themselves down or did they just fall flat on the floor? And then after, were they completely with it or they a bit confused? Um any associated symptoms? So nausea, visual changes, any breathlessness, any chest pain, they had an emotional stimulus. So such as um being in pain or seeing blood, that kind of thing and any incontinence, have they weed themselves, they poo themselves. Um And the important is to check blood sugar in these people. Um You don't want to miss a low blood sugar because that is easily treatable and potentially fatal. Some causes of a transient loss of consciousness. So, vasovagal syncope is a fancy word for it. Just a simple faint. Um So a number of things can cause that um sort of phobias seeing bloods being too hot, that kind of thing. Um And they tend to have a prodrome um which is when you feel sort of um basically, you know, you're about to faint beforehand, um feeling lightheaded, dizzy ears, ringing, that kind of thing. Um dehydration, heat stress, low blood sugar, make sure you check for that. Um, seizures can be a cause of this. So hopefully with someone who has known seizure disorder, um but if they're not known seizure disorder, then it's um more worrying as some causes of seizures can include head injuries and encephalitis. A low blood sugar, very high temperature, um water intoxication, that's a hyponatremia, low sodium, um alcohol withdrawal. Um So it's important to take an alcohol history and strokes. Um A head injury can cause a transit loss of consciousness, a cardiac arrhythmia. So, a funny heartbeat can also cause it and that's a very serious cause of transit loss of consciousness and also alcohol and drugs. So, uh your management, um most of these will just be a simple faint. Um So in this case, so removing the stimulus, so blood pain needles, whatever is caused it. Um sit slash lie down until they improve. So you initially lift up their legs um for a few minutes, they start to improve, lower the legs, make sure they're still all right for five minutes and slowly sitting and standing in the then hydration, fuel and rest as well. Then just considering the cause of them. So low blood sugar, as we said before, um sugary drinks, sweets glu gel. Um if they are heat stressed. Um They want to be cooled down with cold water and you want to target the um big vessels in the body with the cold water. So, um your neck, your armpits and your groin, um and this will cool your core body temperature quicker and seizures. So you want to protect the patients. So make sure they're on flat ground, they're not going to be accidentally throwing themselves off a cliff with the seizure and lie them on their side to protect the airways in the recovery position if possible. Um If after five minutes, the seizure hasn't self resolved, hopefully they're carrying rescue medications if they are known epileptic. Um So this can be in the form of 10 mg of rectal diazePAM or 50 mg of buckles inside your cheek, midazolam and these patients need to be evacuated and you're big sick, little sick. Um So again, your vital signs, um if your transient loss of consciousness has come with chest pain and breathlessness, um this is maybe a sign that it's a heart problem that's causing them to pass out um any seizures or confusion and post head injury. So not during the head injury, but after the head injury, if they've lost consciousness and then just a quick word about stroke, um just with the increasing age of travelers, um this will becoming more common on expeditions. Um So you've got your signs, your fast signs. So a facial droop um arm. This can be arm and leg weakness, arm or leg weakness and changes in speech and then urgent evacuation. Um You can give them 300 mg of aspirin, chewed as well. So well done for persevering through a very long presentation. Feel free to pause any points and take some notes. So take home messages really are the main ones. I'm thinking about. The exact diagnosis does not matter. It is assessing if this patient is well enough to continue to monitor and review and continue or if they need to be evacuated and how and how urgently they need to be evacuated and then your initial appropriate treatment could be the same whatever your diagnosis is. Really. So thinking of pain relief, anti sickness, antibiotics, rehydration, fluids. Um and then at the bottom, it will be thinking about your parameters for evacuation. So what as a medic you're able to manage and who and how you're going to be able to communicate with for advice and for evacuation. If you've got any questions about any of the information that um I've shared, feel free to send me a quick email. My email is on the front slide and hopefully I will be at your week in September. So you can ask me any questions then.