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Right. Hello everyone. Thank you for joining us this evening. Um, to our, um, next session in the seven foundation cases. Um, I'm Boris, I'm one of the, um, coordinators of the seven foundation cases this year. Um Tonight, we've got Doctor George Lewis who's an F two at South Mead Hospital at the moment. Um, and doctor Izzy Sawyer who is an F two at Royal United Hospital in Bar, um, who will be talking you through, um, some medical emergencies and how to approach them on call. A little bit of housekeeping just to start. So if you've not used metal before, there's a chat function and which you can access in the top right hand side of your screens. Um, throughout the talk. If you have any questions, feel free just to post them in the chat. Um One of us will keep an eye on the chat and we'll try and answer your questions as we go along. Unfortunately, you can't turn on your cameras and ask questions like that, but just ping a message in the chat and we'll try and pick it up as we go along. Um, if anything's like not wrong, if you can't, if the slides are too fast or if you want us to repeat something equally, just send a message in the chat and we'll get back to you. Um Don't worry about asking stupid questions they don't exist. Um And at the end, we will just send a feedback link for you all to fill out, um uh which will automatically generate a certificate for you guys to upload onto your accounts to count towards your teaching hours. Um Brilliant. So I will hand over to Georgia and Lewis Geordie and Izzy. Thanks for joining us for today. Oh, thanks Boris. Yeah. So we're going to be talking about upper G bleeds, delirium, agitation and seizures. So it's a bit of a mixture. We were going to do it all in one big case thought that would be a bit much. So let's start with upper G I bleeds and I'll sort of approach these sessions. We're not going to do a sort of revision of these topics in a way we're going to get to go through of what you'd be leaked about and how you react to it as an F one sort of Yeah, going into it, I think definitely both of us agree that these sort of two things after I bleeds and also just the confused patient were some of our most common bleeps that we get and often the most confusing on the night shift that you have to have to deal with. So first the sort of learning outcomes of the upper G I bleed side of things, the sort of things that are expected of us as F ones would be to recognize an upper G I bleed and the severity of that, be able to carry out appropriate investigations of the back of that, initiate that initial management. And then also escalate whether that's a 2222 call or of escalating to the red as appropriate. So that's sort of the set up that we're gonna, gonna go through. So I guess we'll start with recognizing an upper G I bleed. Um, common bleeps that you'll get from the nurses are this patients just had an episode of melena or quick s have got coffee ground vomit. Um That's probably the most common one I would say or the highest suspicion of G I bleed that everyone freaks out about. Um But they could also bleep you because maybe some blood results have come back or patients start to score high news and I think it's just always having it in the back of your head that these are really common things that happen in hospital. Um So many patients over the course of an admission will develop an upper gib and we'll kind of explore why that might be the case. Um But I think it's important when you get a bleed, you've already been working for a few weeks just to kind of ask a few more questions, make sure that it actually isn't Melena or it actually is heis so particularly when it comes to Melina. Um, you're really think of the really dark sticky smelly. It's almost black and tar like is the classic word for it. Um If you're looking at more fresh blood, then you have to kind of consider other things as well. Um And then when it comes to coffee ground vomit, um I think probably the most common difference that I didn't really know about until starting is things like fecal and vomiting. So if people are in obstruction, they can start to vomit up the and that really looks like it. So I guess just having a high index of suspicion, take it seriously, but figure out a bit more and then go from there. Yeah, definitely. Um, so sort of assessing the risk, um and severity of A G I bleed. Um, there's a school system called the Glasgow school that I'm sure that you come across, um, in med school. Um, and it's a system that sort of looks at things like blood, things like urea and hemoglobin and looks at the blood pressures and heart rate and how hemodynamically stable they are. Um And then obviously you've got your other markers that you can score for. So things like melena, um whether they've had a loss of loss of consciousness, syncope, um and whether they've got sort of predisposing disease that might make them more likely um to, to have an upper G I bleed. So all of that you've got to be having in the back of your mind when you come to see a patient with that, have a look at the history. Do they have any risk factors? And should we be escalating this? Um So when it comes to starting management, we thought we divide it into an unstable patient and stable patient. So I guess with an unstable patient, maybe you're on the board already and you are watching someone deteriorate or I guess you're getting a about it, you'd kind of think that they'd be bleeping someone more senior than F one, but it does still come your way as an F one just because you happen to be in the right wrong place at the wrong time. So it be so yeah, just do your ac particularly things like a really low BP. Um That doesn't come up with following like a quick bolus of fluids. Um That would be very like a warning, a big red flag. Um But already uh when you're seeing someone say they're scoring a really high news, just don't have a very low threshold that double two, double two because you're gonna want hands. So I think that's our main take care message from this side. If it's an unstable patient, just be prepared to recognize it. Like the nurses will probably be over there for support as well. But you shouldn't be the only doctor managing someone um really unwell. So, yeah, and then when you were waiting, you can check things like the CPR the respect form. Find out if the escalation status would be appropriate for overnight like ot and things like that and we've put on the right things to do whilst you wait for the seniors. But I think it's with that in the back of your head that there's no pressure. Um, it's just getting help is the main priority in this situation. So that's what we have to say, mom. Yeah, definitely. And then so in the management of someone who's a bit more stable, so you'd be cool to see someone who's maybe had an episode of coffee ground vomit, you go and perform an A two E and you can review their sort of history, any medication they're on. So specifically any anticoagulant medication, um, that they're either on long term, let say the Pix A something like that or whether they're actually on any prophylactic, um BT prophylaxis, anything that could be contributing to this. Um And then once you've got that you probably as long as they're stable. So we've said we've looked at their news and they're dynamically stable. Um, probably the next thing to do is get some access and get some bloods. So things you'd want to do, there are a full blood count, see what Hemoglobin's doing uses and is there risk of urea eyes that's of disproportionate. And also we probably want to get a crossing and a group and save at the same time in case we have to go down the ordering blood products routes and then you can do a sort of apr um, I think that's good to see, you know, has there actually been an episode of Melena, you know, when you is there, that black tarry substance of in the rectum at all? Is there any blood there um, of a lower G I bleeds? That's a really good sort of way to assess. And often like if you call the surgeons about something that they will ask, have you done APR? So it's worth just doing it. Um, obviously they have to be stable. But um, yes off the bat. Um, then you got to think about what medications are they on. Um, so actually withhold any anticoagulation they're on, you can continue that of regular low dose aspirin. But any others we need to withhold whilst we're awaiting investigations. Um And then you really want to be considering, we said, consider blood products if the hemoglobin is below 90. So that's if there's been a big jump below 90 from what it was before, you probably want to consider it. And then the actual values are below 70 then below 80 in a non um in a heart patient. So those are all things to consider. Um, also want to start your high dose IVPP I, um, and then refer for us of an OGD to investigate the cause of that bleeding. And with that, we'd want to make them know by mouth as well the six hours before that procedure and probably give them some IV fluids. Um, and then it's important to make sure that the whole team is on board. So make sure that the, the all the nursing staff are aware that this patient has had a sort of probably having an upper G I bleed. We need to monitor further bleeds, um monitor their observation check. They're not sort of um yes of falling off and then you can hand over any concerns. Make sure you escalate that to one of your seniors. Um either on the ward if it's out of hours to your reg. So if you're ready, we we start with the case. So you've been bleeped by a patient um who's got had coffee ground vomit, three episodes. The nurses say, so this is Frank Mena, a 75 year old man on the care of the elderly ward. He was admitted with an infective exacerbation of COPD. And we're wondering if someone could type in the chart and some questions, things that you want to find out. Um What more do you want the nurse to tell you um over the phone? Yeah, perfect. Yeah. So the observations are key. Really? That's your sort of quick way of assessing. Is this person really un well, with this and unstable. Do they need help sort of immediately or can I sort of have time to properly assess them and look through their, their notes? Really? Um So, yeah, perfect. That's the main thing. So, yeah, so you ask for their s um those the ob on the screen. Um, and then you also sort of go, you go to see them and have a bit of a look at their drug history. They're on Apixaban Ibuprofen, um an inhaler prednisoLONE. Some, you have a look at their past medical history. So in the chat, can you let us know whether you think this is a stable or unstable patient? Yeah, I would agree with that. Um And roughly how would you sort of what we discussed in the previous slide, how would you sort of respond to this bleed? What are your, some of your next steps you do to investigate this? Yeah, you do that. So that's important and you probably, yeah, perfect. That's idea someone's making notes on the computer. That's all perfect. Yeah. Um So what Lily said, bloods are really important, getting access is really important, stopping that Apixaban is a definite um starting PPI so, yeah, that's all perfect. Um So that's your list of things. And obviously it's important to say that it's important to monitor patient sort of throughout, make sure that they're not sort of dropping their BP or there's not more sort of persistent ongoing bleeding And obviously, if you ever feel like adap, I think the most important thing to do is escalate it. Um, if you ever feel uncomfortable, even if it's sort of just you're feeling a bit sort of flustered about it and you just need another pair of hands and some advice, then I would say always escalate. Yeah. So, um, we have some blood results for you. So the hemoglobin is now 75 and the urea is nine. We put in brackets what it was earlier that day or last time I checked. Um, and the nurse beeps you again while you're requesting. The odd to say that there's been another episode of coffee ground vomit which thankfully this time they've saved for you to have a look at and um the news, oh, we haven't calculated the news but we're giving you some new s the heart rate is now high and the BP is a little low. Um, with this change of management, I guess the question. Has anyone got any concerns now about this patient? Are you gonna stick with the original management plan? I think I'd be, I think I'd be a bit more worried about this patient. Yeah. Um, so they're dropping the BP off. Um You can see the heart rate's gone up. That is hemodynamic instability. Um You can see that as well. You know, they've had quite a big drop in their hemoglobin. They've got ongoing. Yeah. Yeah. Eddie. That's right. Um So yeah, a bit more worried about this patient and you think actually we need to, we need to do something here. So we need to up that BP a bit. Um Yeah, chat with the med. I completely agree as well. So yeah, you want to escalate at this point? I think, I think this is a patient who is having ongoing bleeding is becoming really quite unwell with it and isn't being able to maintain their BP. They've had a huge um drop in hemoglobin. And I think yeah, we want to get, we want to get some blood and this suddenly becomes a bit more urgent. OK? Any questions, any other questions before we move on? That was our last slide on G I bleeds. Um If you put them in the chat, we come back, maybe we move on to delirium and agitation. So yeah, with, with these split these into more cases because I think most of you probably from med school know this sort of pinch me acronym and what to look for. Um If someone is confused and if it could be delirium and rule out different causes of that, so we don't want to really go into that too much. We're just gonna go through two cases that I think we've both had on the wards and um very, very common and probably every night shift there's a, there's a bleep like this. So you're on your night shift. Um, it's maybe sort of two in the morning. You're flagging a bit and you get a bleep from, um, one of the ward sisters who says, um, that this 87 year old lady who was admitted with urosepsis, um, and is currently being treated with IV antibiotics, um, has been confused overnight and she's been like this intimacy over the last few days. She's missed several doses of antibiotics. Um, and she's got dementia and at the minute she's putting her cannula out, cannula out, tempting to leave the ward. Um The nurses feel she's a falls risk. Um and they want you to prescribe some medication to calm her down. How would you respond to this bleep? Left one, I'm sure some of you have probably been on this situation already. Um In the first few weeks. Yeah. Yeah, that's really important, I think. Yeah. So it's a confusion screen. Yeah, it's one of the, one of the screens you can do. Um So I think that's really important that you've jumped in with that. I think there's a huge sort of pressure I think because I definitely found um as an f one to, you know, the nurses are very experienced to say I need you to give this patient some LORazepam to calm them down. There's a huge pressure to do that and the nurses are under a huge pressure, you know, they're very busy overnight and are trying to sort of um run the ward and to have one patient and two on the ward who are of using up a lot of their time and resources is really, really difficult and it's important to acknowledge that. Um But yeah, we can't just jump straight into that but to pri patient of their rights and with, you know, without a proper assessment, um that's not ok, so perfect an assessment is important. So I think, yeah, you can do things like the 4 a.m. It's also important to consider the pinched acronym. So is there anything that we haven't sort of taken account of that could be causing um causing confusion? It sounds like this hasn't been new onset. It sounds like it's been sort of coming and going with a clear cause of an infection and obviously looking back through the notes is going to give you a bit more of an idea of that. So infection is probably the cause of her delirium, but it's important to look at the bloods. Are there any changes in electrolytes that might have caused this? Um you know, look at her bowel bowel movements, has she had, you know, is she constipated, would lax do help? And obviously those things aren't going to help in the short term, but it's important to sort of um consider all of this. And then obviously, it's important to talk to the patient and try and calm them down, try and reassure them. Um Sometimes it can just take, you know, a different, you know, the nurses would have tried that obviously, but just a different face coming in and trying to, um trying to sort of calm them down. There's lots of techniques you can do to um help with that. Sort of, you can try and take them back to their rooms and make them settled in their bed and sort of, you know, try and find out if there is anything that we can do from their point of view to, to help. But it is, it is tricky and it is time consuming as well. It's not easy when you've got lots of other bleeps with sick patients coming through, but it's important that we sort of, we do this. So when do you think what things would that you'd start to consider, um, using some form of sedation to help this patient? It's a bit of a broad question. But, um, yeah, perfect, nice. And so, yeah, if the patient is becoming a risk to, you know, so the nursing staff hitting out, um, or if they're actually risk themselves, then that, that is something where you consider actually we might need to, you know, do use some medication to, to help them in this, in this situation. Um, and it's important to say if it's a patient who, um, is, yeah, if it's a patient who's actually sort of violent and a real risk, don't sort of put yourself at risk. So, always, you know, that's what um the security, hospital, security and things are for. Um And the nurses are very good at putting out those calls if you need that. So just say they, they might have done it already. Um But yeah, I never put yourself in the, in the sort of firing line um in those situations, I suppose one thing that we haven't talked about yet as part of the assessment is capacity, which is really, really impo important. So we can't deprive someone of their liberty if they haven't, if they have got capacity. Um So I'm sure you'll all know the sort of capacity assessment. Um The four things that we're looking for. Um And it's important to assess that before we do um before we do give someone sedation drugs to sedate. So we pinch this from, um we, we pinched this from uh like algorithm in ster I think. And it was just saying kind of what we talked about already the deescalation measures that you're probably familiar with that trying to like reorientate a patient or distract them or staff who have a good rale with them. The nurses start with the simple things. If you can get them back into bed, you normally one. but um that's something that you try and then if they're still agitated, which when you've usually been called and you arrive, you have to assess their capacity. We've also then kind of touched on that that you do an assessment trying to find any organic causes. Um, just check and they have been on well earlier in the shift or earlier if they were normal earlier in the day. Um, if they have a background of dementia, things like that, um, you can also have a mental health assessment that I think that's probably unlikely that you'll be doing that overnight, to be honest. Um, and just checking the drug chart, um they haven't had any and that, that they have. So this is basically just what we're talking about. But yeah, because I just had a few questions about capacity assessment. I think it, it's always a tricky one. I think it's when you just, the more you practice it, the better you get it. Um And it's a hard thing to do. I think if you're not, if you're so if you're not sure about it and it's important always to get a second opinion from, you know, one of your senior maybe fleet, the sh or something and see what they can do. I think often I find that some of the questions, the questions that you ask someone to assess the capacity often sort of tie in to each other. So actually checking their understanding is also checking that they communicate, communicate back at the same time. So if you tell, you know, tell some of the information and say, you know, I don't want you wandering around because I think you know, you might, um you might fall over and hit your head and, you know, we're, we're worried about this, that, you know, this could cause harm to you. If they can then communicate that back at the, at that moment in time. And a bit later, then that sort of tells you that actually there is probably capacity there providing that they can also communicate whether they, um whether they understand the risk and the reasons why we're saying what we're saying. So, it, it is hard and I think when someone actually is confused like this, I think often they, they are unable to, to sort of retain that information to even sort of begin to ask these questions or assess. So I think there are some cases that are more clear cut but I think it's, um, I think it's just hard to, yeah, it is a hard thing to do, I think. Um, and it's just something that comes to practice. I, I'm sure I've got any particular tips for it if he is. No, I think it's kind of very individual how far you're gonna get with someone anyway. Like, if you, if they are kind enough to have a conversation with you and actually things in the middle of the night, which is pretty unusual. Mhm. Then, yeah, I think as long as you made an attempt you've, like, introduced yourself, taken some time, been patient, tried again, try, like, if you're getting little to no engagement. That's almost the kind of the cra assessment. It is not complete. But like if they are refusing to talk to you and have that conversation, then I think you've kind of, and on the flip side, you do get patients who, especially with things like self discharges where people I feel like, actually, you know, it's not a decision that you would necessarily agree with. Um, but you actually feel like they can communicate the risk for, you know, they, they don't want to receive the rest of their antibiotics because they want to be at home and want to be relaxing at home. They understand that if they don't take these antibiotics, they might, um become more unwell and become more septic and come back into hospital. But they can, they're able to relay that to me when I ask again. So tell me about what I've said, repeat that back to me about the risks. Um, that I've mentioned and they're able to do that. Um I actually had that on one of my last shifts. The nurses were really asking me to put doze on someone. But when I had a conversation with them, we had a completely reasonable conversation and I just left and I said, I'm really sorry, I know that you're telling me how they were like half an hour ago, but right now I can't put them under do that. They actually have just completely had a rational like, retained everything. We have a normal conversation but then it's completely up to the nurse to ask for a second opinion and they can go and get some to do that. Yeah. And I think it's important to say as well with capacity that it does sort of fluctuate. So, you know, if they're, especially with something like delirium, yeah, they, you know, they can be sort of make a rational decision one minute and then not be the next. So it's important to sort of um yeah, take it at a time dependent point because that's the thing of being time dependent and decision dependent. So I'm sure, you know, this patient that we're talking about now could probably, if they said, oh, I want a glass of water, you know, that's a decision they can make, we can give them a glass of water, but it's um to actually make a sort of bigger decision right now. I don't think this patient that we're talking about in this case would have the capacity to do that. Um So I'm not sure we've really given you any tips. We just talked about the ways that we've struggled as well with, with that. Um But yeah, I hope that helps a little bit, at least fine. Um Yeah. Um So I think that was just highlighting um things that we maybe think would mean that we would want to give her some form of sedation. We'll come on what to give um in a moment, but the fact that actually she is missing treatment, um which, you know, she's gonna miss with UIs and this treatment is going to make you feel a lot better. We haven't included sort of observations and um things like that, but obviously if she was more unwell, this is more urgent that she receives those doses and that's something we have to consider um within that um she's been attempting to hit staff, um that's becoming a risk to them. Um We do need to put a cannula back in to treat her. Um She wants to leave the ward and she hasn't got the capacity to make that decision about her treatment and whether she should go forward. Um and she is a high falls risk. Um And I think that's I see to CJ L of commented on that about nurses asking you to, yeah, asking um saying that high falls risk should sort of necessarily need to, you know, put some under adults. I think it's, it's dependent on the situation if they are in this situation. I think that's completely reasonable. She's walking around, she's, you know, and it's the other thing is of understaffing and not having, she probably needs a 1 to 1 to watch her is actually the ideal in this situation um would be perfect. Um If the other thing wasn't going on, it was just a fool for a situation. Yeah, there should be some sort of a 1 to 1 to sort of help that situation really. But we're often, I mean, the wards are often understaffed. It's really hard to get that. And in this sort of a key situation there's so much else going on that, actually, she probably does need some form of, um, sedation to help her. So, that's interesting. Um, it's come out very well, that's come out very recording. I don't know whether any, can anyone see that last bit of the slide or is it completely black? Yeah. Yeah, it is for us too. Ok. So I think that last slide is just basically talking about the treatments that you would give. Um, and it was specifically the Gloster guidelines actually that I've got from that, which is my first f one job, but it's always important to check your own guidelines. Um, the way that that was split up is if you have, um, Children are sort of a different case, but if you've got people under 70 you tend to give a higher dose. Um, um, and if you give, uh people over 70 you give a slightly lower dose. Yeah. Um So you probably, and it tends to be the over seventies that you treat. So you'd start with an oral um, dose of LORazepam is the first one. So, um, naught 0.5 MGS and then, then you can sort of escalate up up the chain to needing IV S. Um, and things like that. Um, and Haloperidol is the other option, but LORazepam is the first line or LORazepam. Yeah. Um, for all these patients, um, and I think you'd never prescribe it without checking the guideline. I don't just make a guess because you probably guess wrong. And yeah, there are often about three options. You, I'll save you 0.5 LORazepam. They're giving things that Haloperidol just check that they don't have like body dementia and which you've got an ECG on record. Be a bit more cautious. No 0.5 the LORazepam is pretty safe. But then knowing your luck, they'll say, well, we don't have that on the water. And so I guess the story. Yeah. Check your guidelines and prescribe safely. Yeah. What would you do about trying to get a candidate? So I think, I think I would wait until she's more settled. So I think in this situation, I mean, we haven't given the Os and things, but I think in the say you'd wait until she's more settled with the LORazepam and try and, and try and then get that in, I wouldn't do it straight away. Um Realistically she's, she's has missed a few doses, but an extra set of two or three hours and not receiving antibiotic won't make a difference. Something like um if someone's very unwell and needing to receive a blood transfusion or um sort of fluid bolus, that's a different sort of thing. Um But um but Yeah, but with this I would, I think it's ok to wait a little bit. So you've got to sort of make that call, um, sort of with, yeah, depending on the situation really. Um, yeah, good question. Sorry about that last slide. Um, so, so we've got a 75 year old lady admitted with worsening leg swelling. Um, she was started on Furosemide 40 BD in hospital and the nurses bleep you at night because she's out of sorts. You go to review her and she's not orientated. It's a time place or person. This is a new change for her. She has past medical history of chronic kidney disease and heart failure. And so what other information would you like? Yeah. Yeah. Good. Sounds good. Sounds great. I think we give you more than that. Is there anything else that they want to know? Yes. So I think other things to think about is just that, you know, so the reasons for confusion. Um So is she in any, we don't know if she's in any pain at all, if she's, you know, if she's got an infection? So looking at the blood is actually is quite a key thing, you know, especially if it's a new confusion. Is there signs of an infection in her white cells or a crp up? Um Is there any sign that there's any electrolyte disturbance? So what's her sodium doing? What's her statin doing? Calcium magnesium and those sort of things. Um, and so if you can, either, if she hasn't had bloods recently, you can go and take some bloods. Um, yeah, exactly. So, you're right, Freddie, like, clarify a little bit, what's sort of going on as well? It's a very vague handover from the nurse. You want to know what exactly is wrong, you know, is she out of sorts because she's seizing on the floor or is she out of thoughts because she's, you know, just a bit confused. So she's pleasantly confused, confused. Um So yeah, so you want to know a little bit more about what could be causing this and some of the things to rule out. So, yeah, so said pinch me capacity assessment as well and we've given you some bloods here, but um we're already on the system from earlier today, but no one's looked at yet. Um Is there anything that's I haven't given any normal ranges? But is there anything that's standing out to you as not being quite right? Yeah, perfect bottom. Um So I think in this situation that is likely the cause of her, her confusion. So she's someone who's just been started on a new diuretic um known to cause disturbances to your electrolytes sodium and that is likely the cause and if you can probably look back at other bloods and see how acute that changes, um We're not gonna go into the sort of treatment of low sodium in this, in this talk. Um But I think at this point that sodium is quite low and given that, that it's quite a complex case of balancing fluids. I probably even now seeing what's going on, I've had a very similar case the other the other night actually, um where it's trying to balance, you know, she's, she's overloaded, that could be causing the low sodium. But, you know, you got to do full fluid assessment. There's so much to think about. So I probably always um yeah, we always escalate that and ask for a second opinion on the best way to treat it. Um I think we just wanted to drive home that not all agitation is because people are delirious. That is and are many organic causes and they're not things that you will probably sort out overnight that do not go launching into giving patients like this LORazepam or like oral sedation when you've got an actual reason for the change in presentation. So yeah, some and that's the kind of thing that you sometimes don't know until you get there and finally get to review them, which if they're like bottom of your list because you're dealing with someone who's desaturating as well or something else going on. So, yeah, yeah, don't worry anything. And also on the other side of things is if this patient was a bit more like the other patient that was being sort of aggressive and actually you, you couldn't get in a cannula to try and fix that sodium at all. Then actually that's when you would start to consider sort of um yeah, LORazepam or something like that if the escalation wasn't working, but just, yeah, just don't important to see that. Not every confused patient is sort of, yeah, delirious with. No, no. Um So that was, that's four and then we've got a quick bit on seizures. Um It's, it's just a brief thing of the guidelines because actually I think as a, I haven't come across many seizures actually um during my F one. Um yeah, at all. Um But I think the take care message that we want to say that I would always call the senior if someone's se in front of me, you, you need help, I think. Um and it's important to know what comes after that and what to do while you're waiting for help. But I think, yeah, certainly I wouldn't want to be managing a seizure on my, on my own. The only situation where maybe I'd do that is if someone has been having recurrent seizures and there's a very clear plan in the notes and there's been a handover about what to do, but I'd need a direction from, from someone seen it really. So we've actually put that big red arrow there to, there's a cool call for help in that green box below. We put a big red arrow that I think that's where I do it and when we were preparing this, we both sort of agreed with that. Um And then so while you're there things to do in the short term and hopefully the nurses that are working with, you will be able to aid you with this and will be good at that is set a timer because we want to know how long this is going on for. It's really easy thing to forget when it all in the rush of everything. Um, get the patient into the recovery position, make sure that they're, um, airways patent, that's really important. Um, get an oxygen mask on. If you've got time to, you'll probably have help by the time this happens. But getting a BBg and blood is really important, you know, is, is there lact, um, is there any sort of electrolyte disturbance that's causing the seizure? Um, that's what we need to know. Um And then suppose, make sure we've got s, you know, how's this patient, how's this patient doing? And actually, yeah, I wouldn't get too bogged down in the medical side of treating it because I think that's very much at the discretion of the team who know them best or the med ro like, but you're gonna load with, um, leam or like, do you don't really know? So I think just focus on the simple stuff, make sure that you have help coming and in the meantime, yeah, work with the nurses and just keep the patient stable. So yeah, those were our main things. And even if a patient has a history of nonepileptic seizures or functional seizures, I think they often also have a background of epilepsy. You should still, you will never get told off for putting out an emergency call for a seizure. Even if it's stood down pretty much straight away or, and then it will probably help you actually for the rest of the shift, then come up with a plan of what to do if they have another seizure, make sure that before the team disappears, you know, the plan, if it's patient on your ward because otherwise you're just getting the same situation for the next time it happens. And I think, yeah, always as a junior, always assume that it's a real seizure. Never, never sort of think. Oh, I think that looks like a functional one. Always assume that it's real until you've got a sort of, um, opinion from, from someone else. Really? Um, yeah, I think that's all we were really gonna mention on that. If anyone's got any specific questions that we can try and um, help, help answer far away, you can close that it's a lot of black color. So, really? No. So I think that's something that it will often depend. It depends on the situation. I think you've got to rule some other things out first. Obviously, looking at the bloods is really important, um, making sure that there's you know, no new infection that could be causing that. I think anything that's as soon as confusion becomes sort of persistent and either you haven't found a course over the course of your investigations or maybe you've treated the course with what you thought was antibiotics, but it's a bit persistent. Then you'd do that. I think confusion, I think it's a drop in gcs specifically with, when you'd be more inclined to do the CT head. I think if it's just a confusion of GC Ss of 14 and there are other clear causes for it. Um You tend to kind of treat those first and make sure that, that um yeah, make sure that that's those causes that ruled out. Obviously if someone's hit their head um and are on anticoagulation, then, you know, that's, that's a different story. Um But I think definitely that shouldn't be your first sort of go to. But if you're sort of drawing up blanks, you know, looking at things like electrolytes um trying to do some send off a urine sample. Yeah. Um get a chest x-ray. Yeah. So it's probably at the, at the end of your confusion screen and once you've done all this sort of usual things that it is probably a chest infection or a urine infection or some, yeah, the low sodium or something or any new neurology. Yeah, exactly. If you're suspecting stroke. Yeah, but I wouldn't, wouldn't do that before I talk to senior anyway. Yeah, if you were, I'd think I'd have to be a bit worried. Yeah. And I think I would always have clarified that with someone. I'd be like, oh, I've done all this but they're still pretty confused. Do you think a CT head is warranted? And they would, um, you say yes or no? Yeah. Anything else? All right. That's it. Um, thank you all so much. Um, yeah, I've been told to click a feedback thing. I uh have you done it? Uh I think Boris is on it. Yeah. Thanks to Boris and the coordinators for organizing um these talks. I hope that, yeah, I hope it's helpful. Thanks. Thanks guys. See you. The other one I can.