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I think we should be alive now. So hopefully you can see us all here. Um Hi, everyone. Thanks so much for joining. Um My name's Sam. Um It's great to have you all here this evening. Um Thanks for taking the time to come and join. Um If you've not been on here before, um, like I said, I'm Sam, I'm along with Boris. You should be able to see at the bottom of your screen helping to run seven foundation cases this year. Um And we're joined today by EPI um who's gonna be running us through this session on diabetes and sugar management. Um And then looking at death verification and certification after that as well. Um If this is your first time joining, then just if you're not familiar with using metal, then there's a chat function off to the right of your screen. Um So if you got any questions at any point, please just pop them in there. Um And then towards the end of the session, we will send out a little link to complete a feedback form. Um And then once you've done that form, you'll be able to receive which will just automatically generate on your account. Um a little certificate for you to log on your portfolios an hour of non call teaching. So, um if you could do the feedback and then get the certificate that'd be really helpful. Um So yes, I don't think there's anything else particularly to add. Um So without further ado I'll hand over to EPI um and I'll see you all in a bit fab. Thank you very much. Um My name is Ey, I am an F two. I'm currently training at the BR I uh this evening, I'm going to chat to you about uh basic glucose management on the wards. Um I'm basically just, just gonna talk about hyperglycemia um because hypoglycemia is pretty easy and there's a very good protocol for that. And I'm gonna let you know about death, replication and certification and some of the kind of common fit that common it falls uh that you might encounter as an effort on the wards. Um So as I say, we're going to talk about hyperglycemia, we'll talk about HHS DK A and also briefly variable rate insulin infusions. These are the kind of poorly patients that you might encounter on the ward, you might need to intervene in their care. And I'll also talk you through the basic bread and butter, sort of day to day management of raised glucose on the wards. And as I say, def application and certification finally, so hypoglycemia as an F one you're gonna get called about this all the time. Genuinely. Every everyone call, you'll get sort of 3 to 4, probably bleeds. Um, with a nurse saying that a patient's glucose is elevated. The important thing to remember is that you don't always need to act. Um And that the clinical condition of the patient is the most important factor when you're thinking about what to do. Um And you can't go and see everybody with a raised BM. Um as much as you might try to. So if you get the initial call on the phone, um with a nurse saying that you've got a, a patient with a raised BM. Um There's some initial steps you can take over the phone just to gather some more information. Uh The first thing to ask is what was their last blood glucose? So, is this an ongoing trend? Um And you can also ask for their trend throughout the day. Has it been going up and down? Is it labile in general? An isolated hyperglycemia with normal ketones? The first port of call is always going to be to tell the nurse to give the patient a big glass of water and recheck in four hours. So don't kind of jump to do anything straight away. It has to be that they've got persistent hypoglycemia before you really do anything. So, leading on from that, the next thing you need to ask about is their ketones. Are they raised um and also asking us a bit more information about why we're checking. Do we have a diabetic patient? Is it type one? Type two? Are they non-diabetic? Um And also how is the patient? Are they sat, are they chatting? Have they just had a massive glass of Coke and an energy bar that would give us a reason for them to have a hypoglycemia? Um, or are they lying in bed and look like rubbish? And the nurse is worried about them. So those are all the important things to find out. Ebo. There we go. Um So if a patient's blood glucose is persistently elevated, so kind of more than 15/2 hour blood glucose measurements, or if they've got raised ketones, that's the point we need to be considering doing something further. And also if you've got a poorly patient and the nurse says they're worried, then you can think about going to see them. So we'll start with the unwell patients. Um and the kind of presentations that you might see. So if you've got an unwell patient or they've got raised ketones and they've also got hypoglycemia, I'd recommend getting a VBG uh while we're doing a VBG. It's mainly to rule out DK A. Uh So I'll talk through this in a second. But essentially, if you've got a patient with uh raised blood glucose, they've got raised ketones and they're acidotic. You should have alarm bells ringing in your head about this could be DK A something else that you might pick up on a VBG. Um could be something like HHS. So this would be someone who is not acidotic. They don't have a raised ketone. They've got raised blood glucose and they might have very high sodium potentially on a VBG. So that's something else I'll chat to you about another patient group that, I mean, this is just something to be aware of really just to let you know that sometimes when you have unwell patients who are clinically unstable, so they're vomiting, not eating or drinking and they're known diabetic with very labile BMS. They might be on something called a variable rate insulin infusion, which is essentially insulin that runs at a different rate continuously depending on the patient's blood glucose. Uh you can do it presurgery, but you also might see it in patients who are septic or very unwell. Um And it's where you need to have good blood go blood glucose control. Um And if you have someone that is unwell with persistently raised blood glucose, a variable rate insulin infusion is something you could think about starting. Um I'd probably chat to a senior before you do that fine. So DK A, as I said on my previous slide, um this is when you've got hypoglycemia acidosis. So a ph of less than 7.3 on your VBG or importantly, if you have a bicarb of less than 15, um you also have serum ketones of more than three millimoles per liter. The important thing with DK A is that these are really poorly patients in general as an F one, I would say, the most important thing is to be able to identify it. So think about, you know, doing a VBG if you've got a patient with raised ketones starting that initial a assessment, potentially starting treatment if you feel confident about doing so. but definitely, definitely calling for a senior review as soon as possible. Um You don't want to be going to handover at the end of the day with a patient that's in DK A and hasn't been seen by a senior or a senior isn't aware of them. Um So definitely make sure they do that because they might need to go to it for management. Some, sometimes um One other piece of advice is get familiar with your local protocols because DK A patients can be poorly and they are complex. There is always a very solid protocol in your local area. Um So if you find a patient that you think might have DK A, I'd advise getting online, printing out the protocols, having a good read and getting them in your head before you do anything, but just a quick run through of the basic principles. Uh So essentially, I'm not gonna bore you about the pathophysiology, but these patients are in massive fluid deficit. Um So we need to rehydrate them um and we also need to bring down their ketones and to bring down their ketones, they're going to need insulin to allow the, the cells to properly take up glucose and to leave ketosis essentially. Um And that rehydration combined with giving insulin is what's going to resolve the acidosis and allow the patient to come out of DK A. So fluid wise, um you start off if you review the patient, you do your initial A two E and they've got uh low BP, then you can give a fluid bolus. Um You can repeat that up to three times on our local protocols. I'm not sure what everyone else's is, but generally, if you've got a low BP, get senior advice sooner rather than later and you can give a fluid bolus. Um and then you'll be giving fluids. I know that the, the rate will probably vary based on local protocols, but essentially you're starting with a fast bag. So around an hour and then you'll generally give our in our trust. At least you give 22 hourly bags, then a four hourly bag, then a six hourly bag. Um and you'll be assessing the patient for risk of fluid overload. So if they're an older patient say they've got a history of heart failure, um they'll probably be a slower rate at which you can give those fluids on the protocol. The other thing you'll be giving is a fixed race insulin infusion. Uh this is based on the patient's weight. So in this situation, I kind of think of insulin as the drug almost. This is the medication that we're giving that's gonna push the patient out of TK A patients have side effects and essentially this effect giving insulin with hypoglycemia and hypokalemia. So, occasion with UK A, those are things that we need to continue to treat as we get. So, no, for some reason, my next side is not quite loading, but tension, potassium, regular VBG to double check what the potassium is. Um And that should tell you the rate at which you, you should replace it. There we go no faster than 10 millimoles um per hour. And then you also will be giving potentially alongside the insulin IV dextrose. And this to me seemed really counterintuitive when I first started while you're giving insulin and dextrose. And the reason is again, you're thinking of insulin as the drug that's allowing your body to move from hypoglycemia into normal glycemia and you need the insulin to push ketosis. So the dextrose basically acts as a substrate to allow the insulin to continue to act without the patient becoming profoundly hypoglycemic. So that's what you need to do. Fluid plus minus some potassium and then insulin plus minus some dextrose and you'll continually monitor uh for those things. Oops. So here we go. So things you need to be looking out for are going to be hypokalemia as I said, you might have to add some potassium into your saline. Um You'll be looking at for hypoglycemia. You might need to give um dextrose alongside and you might need to alter your fluid, uh sorry, your insulin uh infusion rate and you'll also be looking out for signs of fluid overload. So all of these things, you'll be monitoring regularly. You should be getting regular bbgs, um and regular or I think hourly ketones and B MS. So essentially, eventually you will reach a resolution criteria, which is when your venous ph is above 7.3. And your serum ketones have come down to less than 0.6. Once you're at this stage, generally, I would just speak to a senior about changing them off the fixed rate insulin infusion. Most often patients will start after they finish fixed rate and they've reached resolution. They'll go on to a variable rate insulin infusion. Once they're ready to eat and drink again and take their normal insulin as they normally do, then they will go back onto, um they'll go back onto their subcutaneous insulin regime, but that will be done by the day team most likely don't do this kind of thing overnight or on a weekend if you're not sure. So my summary slide for DK A is if you've got a patient with a raised BM and raised ketones, get a BBg if they're acidotic on that BBg. Uh then Alarm Bell should be ringing for DK A. So recognizing those key criteria as an F one, you're never expected to treat DK A alone, um that would be quite dangerous. It's a complex um medical condition. Uh So always ask for help early. Uh make sure you're getting a senior review uh because these can be poorly patients and they can get unwell quickly and also make sure you're familiar with your local protocols and that you're happy with where to find them and to print them off if you need to. OK. So next, I'm going to talk about another type of poorly patient uh with raised B MS, this is HHS, hyperosmolar nonketotic state. I'm sure you've heard of this. Uh This is similar to DK A in that it's poorly patients who you shouldn't be managing alone. Um So for this patient, you might find someone with a high glucose and you do ketones which are normal, their ketones shouldn't be raised and if they call HHS and then they are not acidotic on that BBg. Um And you might see on the BBg that they've got high sodium, for example. Um And that might point you in the direction of HHS. So once you've got a suspicion of HHS, you can calculate the patient's osmolality, which will be as I put on here. If your osmolality is more than 320 you have the criteria above, then you're thinking HHS and I'm just going to say that this is supposed to be quite rare, but I have seen three. So it can't be that rare. It generally is something that's identified like DK A on the door. Really. It's generally people come through D and you know that they've got it. So your most common call will be going to the wards reviewing BBGS, maybe doing a fluid review. Um, and kind of just checking the protocol and represcribed fluids. You're unlikely to be diagnosing these patients in the first instance. But this is just so the you know what to look out for. Um So once you've realized that the patient is in HHS, the primary princip principle in these patients is to treat their dehydration primarily. So these patients are often hugely hugely dehydrated because unlike DK A, they've not gone into this massive ketosis. It's made them really unwell and present very quickly. This can be a gradual over kind of days or weeks really of the patient becoming more and more dehydrated with a very high BM. Um And yeah, to deficit is a huge amount. So you need to really try and load these patients with fluids, obviously, continue with your regular fluid reviews. Um The important thing is that so you initially don't need to start insulin in these patients. Uh You just give them some fluids and their blood glucose should start to fall with hydration alone. If their blood glucose stops falling with fluid alone, you can look at starting very, very, very slow rate, insulin. But what you want to look out for with all patients in HHS is to not drop their osmolality too quickly. So that's the equation I've showed you up here with sodium glucose and urea. Um if the osmolality drops too quickly, they're at risk of cerebral edema and cardiovascular collapse. I think it says on the protocol. Um so just need to keep an eye out for that. Again, it's on the protocol. Uh but it might just be a case of adjusting insulin infusion rates if they're on insulin um or adjusting fluid rates. So again, um I'm going to just do a quick summary of HHS that you need to suspect HHS. If you've got persistently very raised BMS with evidence of severe dehydration and potentially raised osmolality, you need to familiarize yourself with your local protocols. Remember that you're never expected to treat these kinds of patients alone and that they can be quite poorly. Um And they might need admission to ICU. Oh, I just mentioned here as well that there's occasionally you can see patients in HHS who are also um acidotic. It could be that they've got kind of a lactic acidosis, maybe they've got um kind of a sep sepsis that's pushed them into HHS in the first place. Um Sometimes they can have raised ketones and there might be a bit of an overlap between DK A and HHS in that scenario. Um in that situation, you'd start insulin infusion earlier and you'd also speak to your senior. Uh just about what you do in that scenario. Fine. So I've got a quick case here if anyone wants to answer some things on the chat. So you get a call from a nurse telling you that you got a 56 year old gentleman. He was admitted a few days ago with a chest infection and his blood glucose is 26. So what kind of questions? What extra information are you going to try and get from this nurse? Just pop anything in the chart. There we go. Is a patient diabetic. Great. Uh Yeah. Good question. Are they diabetic? What are the ketones? Where are we holding their B BMS? Perfect. Yeah. All of those things. So, yeah, exactly. So and also you can ask about the kind of trend in there. Yeah. There we go. Good enough. What are we doing? And the trend? Um So we found that ketones are four. The last blood glucose was 24. We know that this patient is type one diabetic and they are eating minimal amounts. So, what is your next step going to be? Perfect. VBG. Always do BBg. If you've got someone with raised ketones and raised BM, you need to rule out any chance of it being um uh Yeah, fine. What's this? Uh can I use? Well, pressure and risk of ketosis? We'll chat about that in a bit. Is that OK? I'll come back to your question on that. Um So ketones. Yeah, for last BM 24 VBG is 7.525. So we know that they're acidotic in the case that they've got raised ketones and a raised BM. Um So what do we want to do? What's our plan at this stage? Great. So you're asking the right questions, your, your plan is that you need to go and do an A TV assessment and assess how they're getting on. Um So a two assessment, do a fluid review, get access and call your senior and print out the DK A protocol. Those are the things I'd recommend doing in the first instance. Lovely. So this, this looks like it is DK A fine. So I'm gonna now talk about well patients um and remind you that. So I've talked about kind of the very sickest patients. Now talk about the well patients and remind you that actually an isolated hyperglycemia in a well, patient is not necessarily a major cause for concern. Um If their ketones are normal and the patient is stable, as I said, at the start, our first instance is going to be making sure that the patient is properly hydrated and monitor and check that their BM is kind of stable. I would say honestly, about 80 to 90% of calls you get about raised BMS. If you just ask the nurse to rehydrate the patient, they won't call back about it after the next check because their, their glucose comes down. Um nurses because they are checking, these patients can become a bit kind of nervous about raised glucose. Uh Don't be pressured into going and giving stat doses of um insulin. It's not necessarily the best practice. Um And yeah, just don't be pressured into reactively treating. So first of all, I'll, we'll briefly look at these special circumstances. So if you've got a patient that's well and they're hyperglycemic, you might be looking for reasons that they could be hypoglycemic. Um So things like pregnancy uh steroids, if they're on TPN or if they're on an insulin pump, all of these things have special circumstances, special guidelines which should be on protocols in the hospital. I'm not going to go through all of them. Um But just to make you aware that these are all things that can bring up your blood glucose. If you find a patient in this scenario, have a look on your local guidelines and look at the treatment for these, then you've got patients that be known diabetic. So how do you manage patients that are known diabetic if they are fit and well and able to tell you what's going on, you can ask the patients, how do they normally manage their blood glucose? What are their sick day rules? And do they normally give themselves corrective doses and they might well be able to do that themselves with support from the nursing staff on the ward. Um, same for type two diabetics. Really? You're just thinking about what do they normally do to correct their blood glucose? Um, and you can consider up titrating their, um, normal anti diabetic meds. There is a third category, um, which I think is pretty rare. Really. I've not really seen, seen any of these, which is patients that are not known to be diabetic. Um And that don't have any special circumstances. You can't see any reason that they're, um, they've got had a BM spike for these patients if they're well and their ketones are normal. Um I would say in the first instance, rehydrate them and then just recheck in a couple of hours and make sure that they've not been kind of drinking Coke or had dinner recently. Um, then you could get a g it could be sensible just to reassure yourself that they're not patho. Um, and then monitor that I would discuss with the senior regarding ongoing management if overnight. Um, and do a referral to the diabetes team, they can review the patient the next day probably if they're stable and well, um, we don't need to be too concerned fine. So, um, just regarding how to up rate and what we look for up, up, up titrate uh insulin or anti diabetic drugs. So first things first is the obvious stuff, really review their drug charts. Um, see what medications they're on, see if there's any scope to increase or, uh, or hypoglycemics, just check the BNF for those. Um, that's not really something you'd be doing overnight. So, obviously, um, you might consider it, uh, if, if you're just generally reviewing a patient during the daytime, um, you can also look at their blood glucose chart that's really important and look to see if there's any trends and there times of the day when their blood glucose is coming up or when it's coming down. Um And the other thing that seems obvious, but I often forget is to check through their notes and see if A DS N or diabetic specialist nurse has previously reviewed the patient. So that happens quite a lot. So for patients on um steroids or if their blood glucose has been poorly controlled, they've often reviewed the patient a few days ago and given some advice about what to do if their ongoing um glucose control problems. So you can just follow that advice. But in general, if a patient is on twice daily insulin, you can look at increasing their morning or evening dose by about 10 to 20%. Uh you want to be really kind of low and slow with these things. Um You don't want to push the patient into hypoglycemia inadvertently. Um And I would recommend that you look at when the patient is becoming hypoglycemic. So it's often that they're becoming hypoglycemic, say in the daytime or at night time and then you choose which dose you need to change accordingly. Similar story really for, if a patient is on a basal bolus regime, uh you can increase their long-acting insulin if they're hypoglycemic when they're fasting. If you're finding that it's after they've eaten, uh that they're becoming hypoglycemic, then you can look at increasing their short-acting insulin again, very small dose adjustments at one time. And if they've got ongoing issues with insulin with their blood glucose control, I just do a, a diabetic specialist nurse referral and they can review the patient um corrective doses. As I say, generally, we try to avoid corrective doses. Um There's two reasons really. First of all, you don't want your patient to become hypoglycemic. Um especially if they've not really had much insulin in the past. So say, for example, if you had a patient who is completely insulin naive and taking steroids, if you go in and give them a dose of, of nova rapids, you have the chance of dropping their blood glucose quite significantly. Um And yeah, it's hard, it can be hard to treat. Uh Also your, if you give them of lots of repeated stat doses of insulin, it's quite hard to assess their trends in blood glucose. And it means that it's quite difficult to prescribe longer acting insulin if they do require it. Um So try to avoid it if you possibly can. Uh you can consider it if their blood ketones are more than 1.5. Um, and, you know, especially if they already take insulin. Normally you use Novo rapids. Um, and you monitor the cap your blood glucose for two, about four hours afterwards, two hourly and don't give more than two corrective doses um, in any one time. Uh Just, yeah, if the glu glucose isn't coming down after that, I would talk to a senior. Um, the important thing as well is what dose to give them? Generally a unit of novo raids will reduce a patient's blood glucose by about 2 to 3. So I tend to err on the side of caution and say that we'll probably reduce the blood glucose by about three. Also, um, you're, you're supposed to be aiming for a target glucose when you're using novo rapid of around eight, I tend to go for about 10. So say for example, if a patient has um like a, a blood glucose of 19, you could give them sort of 2 to 3 units maximum. I'd always err on the side of caution, maybe just give, yeah, two or three, see how they get on with that. Um But less is more really, you don't want to overdo it with these corrective doses fine. So um we're gonna chat for another case. Now, this is a well patient. I shouldn't really tell you that. But anyway, 65 year old gentleman, this is what you're called by a nurse to inform about um he was admitted following a fall and his blood glucose is 19. So what questions should you be asking? So it's, it's similar questions to our previous discussion. Really? Um You is this like a routine set of questions coming up. Diabetic keto is gonna be entrance. Exactly. Perfect. Um So we find this information from them. Ketones, 0.1 last blood glucose is 23. So they are persistently quite elevated. Um They're eating and drinking well, and they're type two diabetic next step for this patient. Lovely, perfect check with her on then review their drug chart and review their um blood glucose chart as well. Um Is a good idea. See what times of day that they're um hypoglycemic. If you're looking at their drug chart and you're realizing, oh, this is actually been going on for quite some time. They're kind of persistent, persistently hypoglycemic. You can't find any reason that they would be hypoglycemic. So that's the special circumstances I was talking about. They have their own protocols. So, things like are they on steroids? Um Are they on, do they have an insulin pump that might have malfunctioned? Are they on TPN pregnancy? I think that was it. But yeah, have a look at those and if you can't find a reason for that fine. Um And you look at this patient's chart and you find that they are on Lantus twice daily, uh, they're 18 units in the morning and they're on 20 units at night. Would you give this patient stat insulin? And what else would you do in the chat coming through quite early? But essentially, I've just said that they're not for sat incident at present. They've not got any of the, um, their ketones are not 0.1. So their ketones are 1.5 and they need it. Uh, you could consider at this stage looking at here we go 18 to review if it was a night, if it was night, otherwise ask a seem you should be a 10% change. Yeah, I think that's completely reasonable. Um If it's overnight and you're not worried about them, then you could just ask the nurses to continue monitoring and then get the day team to have a look. But otherwise, um you could think about changing the evening or morning dose of insulin by a little amount um and refer to diabetic specialist nurses if you're having ongoing issues with hyperglycemia. Lovely. So just a quick recap again. Always start by asking for extra information over the phone about any patient. Um Don't be afraid to ask for help, treat the patient, not the blood glucose and consider treatment or review of persistently elevated blood glucose if they've got raised ketones or if you're concerned about them being unwell, avoid that dose of insulin as they can lead to Hypos and refer to the DS N or the specialist nurse if they need. Lovely. So we're going to move on to deaf verification. Now, this is a super common call as an F one. You will get called to it quite a lot. Um Couple of bits of advice. I would say that when you get the call, ask the nurses, first of all, if the family want to be there for the verification because sometimes they will want to stay and kind of watch you do it. In which case, you kind of need to get there sooner rather than later. Um, because you don't want them sat in the room for kind of an hour. Um Otherwise these patients are not necessarily your priority. If you've got sick patients, you might need to explain to the nurses. I'm coming as quickly as I can, but there might be some delay and often the families are very understanding of that fact, as I say, do try and get to them sooner rather than later because as we get to, you will be putting down a time of death. And if the families think that that was, you know, six hours ago and they know that they died six hours ago, they might be a little bit cross about it on the death certificate. Um And the other thing is if you're doing them overnight and there's a change in day, I'd always try and get to those patients the same day because otherwise the, the, the death we verified as the day after that patient has passed away if it's past midnight. And so if you can, it's great. So just the general, what do we do? I'm gonna speed through this because you should be able to find uh a list of things to do online. There's a really good geeky medics page if you just Google de verification, um geeky medics and it will tell you all the different things to do. Um So first of all, don't forget to verify their identity, check their name on the wristband, check for a central pulse. Listen for heart and breath sounds observed for movement. You should spend about five minutes total doing those three. It doesn't really matter how you split your time, but kind of yeah, about a minute and a half on each of those things, then shine a light in the patient's pupils um and confirm that there's no response to light. You can use your phone torch for this. You often will end up using your phone torch for this. If the family is present, I would always try and see if there's a pen torch available to use. Um But if you can't, don't worry about it, um apply super orbital pressure and see if there's a response to that. And finally, as a favor to yourself, potentially and your colleagues uh just have a little bit of a feel um for a pacemaker, they're generally pretty easy to feel and you can just write no pace, no pacemaker, uh palpable. Um Then you fill out your time of death is the time that you verify that all of these criteria are met. Unfortunately, you can't backdate this. Um you the time that you've come and review the patient, that's the time that you put down as their, their time of death. So death verification in some hospitals, there will be a form that you just kind of fill out and it will tell you all the things we've now got one that's like a check box and you just take to say no pulse, no signs of breathing, et cetera. But if you don't have that, this is also on the ki medics website, Google death verification, Kome. This will come up and you write out all of these things have been met um and clearly document in the notes and this is really important if there's no form in your hospital and put that in there with your GMC number and a and you have to say a time and a date. Ok. So moving on to death certification, uh this is different that death verification. Um death certificates need to be written within five days of the patient passing away. Um They need to be done by a doctor who's met the patient in the last 28 days alive. And generally you need to have a chat to the consultant who's in charge of the patient prior to filling these out. Um, it just gives you a better, better idea of uh what they think the cause of death was. Um, and generally that that will be an accepted cause of death. So don't worry too much about, um, knowing what one A one B, one C are on the side here. Um Basically what will happen is you'll get probably an email from your bereavement department asking you to come and complete an the death certificate. If you've met the patient in the last 28 days, um You'll head down to the bereavement office and you will look through the patient's notes. You can also look at things like chest xrays or um see if they've had any um hip operations in the past to fix you on hip, please. Can you speak slowly because the network in my country was bad and a lot of information lost. I can slow down my speaking. Um Let me know if it's, if, if it's not clear. So, um as I was, as I was saying, so you, you can look at their chest x-rays and you can look at um potentially hip x-rays if you're not sure if they've had um kind of hip implants in the past. Uh There's a particular type called pyin which can't go through a um can't they through with the creme cremation machines? What do they call them? They can't go in the cremation machines. Um That's more important if you're doing a cremation form, that's not actually relevant for the death certificate, but just to let you know what happens when you go down to the breathing office. So this is the death fate. Uh You will look for the patient's notes and you'll look for what you think was the main cause of death. It's important that this is not a mode of dying. So you can't put something down like respiratory failure, you can't put something like acute heart failure. Um You can't put coma, for example, if, if it was respiratory failure that you think cause the patient to pass away, you put pneumonia or what was causing that respiratory failure. Do you see what I mean? Because it's kind of nonspecific, it doesn't tell you what was causing those organs to fail. Um The exception is you can put chronic heart failure, but you can't put acute heart failure, you then put in one B factors that are leading to a. So uh factors, for example, that would be leading to pneumonia, you might have COPD. So it's a direct kind of chain that you're looking at. And then one the um you put, if there's a clear, direct cause and effect, you can put another factor that's leading to be um often you won't fill all of these out. I quite frequently will just put one a down as a cause. And then in two here you put other significant factors. Um So for example, if a patient had COPD and they died from that, um, and, and pneumonia, you might put ischemic heart disease and type two diabetes as kind of contributing factors that you think hasten their death. You put here on the right hand side, the approximate interval between the condition onset and death. Uh So for example, if they had pneumonia, that could be days or weeks, um, and then if you had, um, uh, sort of other significant conditions like uh type two diabetes, that would probably be years. Um I just had a question through saying, well, the common sites for subcutaneous defibrillators, um, you basically just feel over the chest wall on the left hand side. Um, it should just be kind of up and around here. I don't know if you can see where I'm pushing. Um, yeah, around here basically. And generally, if it's a pacemaker, it will be quite large and chunky and you'll be able to quite clearly feel it. Um, and if you're concerned or you're worried if they, if you don't know if they've got a pacemaker, you can look at the most recent chest x-ray and you should quite clearly see something. And if you're ever worried, just chat to, um, the bereavement staff in the office. So certain causes of death will be referred to a coroner. Generally, these are things that, um, there's a query about kind of negligence or if they were preventable. So things like um, aspiration pneumonias, um, might be referred to a coroner if there's a, if there's a thought that they could have been prevented. Um, so for example, if there was someone that was left alone when they shouldn't have, if they were feeding at risk, all those sorts of things might need to go to a coroner. Um, anything related to a patient's work. So, for example, asbestosis, if they, if they've been exposed to asbestos, anything that's contributed to their death, that will have to go to a coroner as well. Um, but in general, don't worry too much about this because um, there will be uh uh someone to talk you through it down in the office. So this is case three, we're going to briefly chat through um, a 67 year old gentleman who was admitted with raised respiration and tachycardia. Um, in type one respiratory failure, they were found to have a bilateral pneumonia despite antibiotics and um, noninvasive ventilation. This patient deteriorated, sadly, passed away. They've got a background of COPD ischemic heart disease, Alpha, antitrypsin alpha one, antitrypsin deficiency and type two diabetes. Um, so just quickly, um, can anyone just type in the chat very quickly what you need to check to confirm that the patient is dead? Yeah, I'm not gonna spend too long on this, but essentially all of the, oh, here we go. Yeah, someone's answered. Lovely. Central P Pupi reflex, breathing sounds, heart sounds pain, reflex, lovely. Um response. I've got lots coming through now. Perfect. Um Always remember to check patient identification as you go in as well, check the wristband. Um I that's easy to forget. Um you sort of walk in, walk out. Um Yeah, fine, lovely. And then the next thing I'm going to ask is what are you going to be writing on this patient's death certificate? Um I've put a little reminder here of uh what the different one, A one, B, one C and two means. So, yeah, perfect. Uh So a pneumonia and the main cause. Lovely 11 B will be COPD, which is probably led to the pneumonia. Um, and then alpha one antitrypsin, the natural uh kind of history of that disease is that it can cause COPD. So that would be a good, uh, one C and then ischemic heart disease and type two diabetes as other significant factors, very well done. And I think it's really rare to be honest that you'd have, um, a patient having all of those things filled in. Normally, it's just kind of one A, maybe A one B and then two. and you can put multiple things in these um, sections. You just need to write, uh, both of the things and then put in brackets next to them a joint cause if you think there was two things that cause the patient to pass away. But again, that's pretty rare and you'll be guided very much by um the team here in the office. So, thank you very much for coming. That is everything. Um I think I had a question about uh DK A up here somewhere. Do do so, can we talk about SGLT two inhibitors and the risks of euglycemic ketoacidosis? Um So that is a good question. Um So generally, if you've got any unwell patients, you should be discontinuing SGLT two inhibitors due to the fact that they um patients can develop eugly euglycemic ketoacidosis. Um If a patient is on an SGLT two inhibitor and they're unwell, um check their ketones, irrespective of their capillary blood glucose um and make the, make sure that they're adequately rehydrated. If they've got raised ketones and um then do a BBg and if you're worried about them, then speak to a senior. It might well be that you need to start them on um on treatment for uh euglycemic D um ketosis. Thanks so much. That's great. That's so helpful. Um Unless there's any other questions, um we will stop that m tracking. No, I think that's everything. Um Thanks so much. That's so helpful. Thanks everyone so much for coming. Um The link has just appeared in the chat for providing feedback. So, if you could fill that in now, please, um then you'll be rewarded for your time with this nice certificate for you to log on your portfolio. Um So don't forget to log that on Horus. That's one hour of non core teaching. Um, I'll keep saying that you probably think you're going to get your 60 hours. Absolutely fine right now. But I'm sure with on calls and long days and all sorts, you'll be getting around to April time and starting to worry a bit about your teaching hours. So, um, really useful to log that now. Um, and then I'm just going to post if you bear with me one second, the link for next week for the next session, which is this Thursday. So that's just on there now. Um So if you click on that link, you'll be able to register um for the next session. So that's this Thursday. We're going to be looking at some various medical on call scenarios. So upper G I bleeds um seizures, agitation, delirium. So, um not specific to medical jobs. If you're on a surgical job as well, you'll, I'm sure you may well encounter patients with all these sorts of problems. So, um another really useful session coming up. Um And I think that's probably everything. So yes, ah log that out on your portfolio, fill in the feedback and then you'll get that certificate. Um And otherwise we'll stop there. So, thanks everyone for coming and hopefully see you on Thursday. Thanks, Eppie. Thank you very much.