Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

right. Hello, everyone. I hope everyone can hear us. Um, please write a comment in the chat section if you can't hear us. Um, so this is the first webinar of three lectures on the CST interview. Um, we've been lucky enough to have Gary keep presenting today. Thank you for letting me know you can hear me. Um, Garrick a is a core surgical training in his first year in London. Um, he's doing a plastics themed job at the moment. Um, he applied last year and scored ranked in the top 1% of all applicants, which is in credible and scored a whole 96% in his court surgical training interview. So we're very lucky to have him here today to take us through some tips for smashing the clinical section of the interview. And so if everyone's ready to start, we'll leave it to you. Garrick a, uh perfect. Thank you. Thank you so much for your for that very kind introduction. Hi, everyone. As Freya said, I am a CT one currently Chelsea Westminster doing a plastic surgery themed post. Um, Freya asked me to essentially just give an overview of the court surgical training interview, which I believe is coming up in a few weeks time more specifically focusing on the clinical station and even more specifically on the crisp, um, sort of aspect of that. So I'll I'll do my best to answer as, um as many questions as I believe you might have. I'll mostly focus this talk based on of how I approach the interview and what I found to be useful and sort of the structures that I developed to help me, um, answer uh, specific questions within the interview itself. Um, ideally, I would have liked this to be interactive, but I I don't imagine I'll be able to speak to anyone. Um, but you know, if you've got any questions, just throw them in the chat, and I'll try and answer them when I can. Um, so hopefully without further a do and let's get started, I'm working. Oh, perfect. So she's clicking. So introductions out of the way. Um, I have to apologize by my slides are actually just fairly basic and just clean. So, um, it'll mostly just be me talking. They'll be prompt on the screen. Um, but yeah, Hopefully you shouldn't get too tired of my voice, but basically so. The session outlined for today is obviously, as I said, I'll be going through the CST interview format for 2023. Um, I'll be going through a few of the resources that I used personally and how I prepared for my interview last year. I'll go through the crisp algorithm as well. Um, as obviously, that's quite important to understand before you go for the interview. Um, this is particularly pertinent for, um for people that may not have sat crisp. Um, you know, for those who are you know, F two s applying for CST, you may not necessarily have had the opportunity to attend a crisp course. Um, so this may be fairly useful and also how to structure your answers. So I'll go through a few frameworks that I use myself to help structure the answer within the interview, and I'll go to help illustrate those points. I'll be going through a an example scenario as well, and finish off with some general tips. Okay, Um, so this is all sort of, I guess, Fairly common knowledge. I'm not going to spend too much time on it. Um, as Far as I'm aware, the CST interview format for 2023 should still all be online. Um, last year, when I sat the interview, this was on Microsoft teams. So the structure is. It's a 20 minute interview divided into 2 10 minute stations, one of which is a clinical station, and the other is a leadership, leadership and management station. Um, your clinical station, uh, is further divided into sort of. I guess you can broadly categorize them into either an A. T l s or trauma uh, station where all your questions are trauma related, as well as a care of the critically and uh, ill surgical patient station, uh, in which you're often presented with a patient who's in, well, often post operative or just a generally unwell patient that you have to assess and manage on the ward. You usually have to interviewers. Often these are consultants, but you can't get a mixture of a consultant and a senior registrar, So don't be surprised if you get one of the two. And overall, the interview itself is worth 100 and 44 points, which is a whole two thirds of your total score, so as you can imagine, it's quite important to, uh, to make sure that you're you're well prepared and you can approach the interview as best of your ability as possible. Um, and this, you know, requires a lot of preparation beforehand. And, um, as well go through in the next few slides. So your preparation, Um, well, I guess you know this. This depends on each individual. Some people are more calm, confident with interview, um, interviews in general. Others Not necessarily. Um, myself, I generally wasn't. You know, I'm not the type to to perform, um, confident in interviews, so I often require a lot more practice and a lot more preparation beforehand. So I started preparing roughly 2 to 3 months before, um, you know, starting fairly slowly, interview practice here and there with friends and then progressively increasing the intensity, practicing every day, practicing multiple times a day until the day of the interview. And if you think about it, this This makes a lot of sense, right? Because as an interview is essentially a performance and you don't want the first time that you're saying some of your answers to be on on the interview day you want to have rehearsed and fine tuned your answers so that when you say them on interview day that there is a sink and as clear as possible. So with this in mind, my first bit of advice and, you know, this is completely sort of, I suppose, obvious. And, um and I hope I'm not teaching to suck eggs, But I think it's I can't, you know, understate the importance of just practicing, saying your answers verbally. You know, this. This could be saying your answers in the mirror when you wake up. As sad as that sounds, sometimes it can help. But what I find to be incredibly useful was to have an interview practice partner. So this could be someone that you're applying with in the same year. You know, every evening after work, you spend an hour practicing with each other. This is good because it encourages accountability between the two of you. It also means that you're practicing with someone that you know, Um, it's not as high pressure. Um, you can sort of pick things up from the other person that you may not have necessarily considered. It's just a good way of getting into that mindset of speaking confidently and naturally until you sort of can fine tune. Your response is closer to the time once you've had some time to build your knowledge base. Um, and this can be done using either books or online resources or even, uh, in person courses. You can then start to practice with current court trainees because you know, these are people who have gone through the experience that you're going to go through that you're going to go through. So, uh, you know, these are probably the best people that you can actually practice with because it's fresh in their minds. Most CTS that I know are always willing to help. Um, and they probably have a bit more time on their hands than registrars and consultants there. A bit more approach, a bit more approachable. And I guess it also helps them with, um, sort of teaching points. So practice with court trainees whenever you can, and finally to to add that extra element of, I guess, pressure, which you know, is fairly representative of the interview itself. Try and get comfortable speaking to registrars and consultants, um, going through clinical scenarios and answering them in a structured manner to develop. I suppose that that that that mindset which would help you on the day of the interview so common resources um, these are all fairly, uh, I suppose well known, fairly standard. Um, I should really have included some images on my slides, but there's the green and White book, which is of the classic, you know? So of course it's called training interview book that everyone uses. Um, I used that as well personally, and I think it provides a really good background, um, to help build your knowledge prior to the interview. The one downside I have to admit is that it's it's a fairly sorry, fairly outdated text book published in 2015, I believe, um, therefore, some of the scenarios may not necessarily be up to date. Um, it doesn't really cover clinical scenarios in as much detail, um, if at all. So you know this. It's a good resource, but it's also still supplementing with other resources out there as well. For the, I suppose, for the clinical governance aspect and some of the management questions the I SCP Medical Interview book, which I believe is a white one, um, with small icons on the front cover. That's quite good for all your management and leadership style questions and all your ethical scenarios as well. Fine. So with that sort of out of the way, um, obviously I'll be going through the clinical station and I'll be focusing on the crisp algorithm now. I When I applied, I hadn't sat or attended a crisp event, and I don't think F two s are eligible to attend a crisp event. So I think it's fair to say that most of you going into the CST application process won't have had the opportunity to attend. But there are still resources out there that you can use to help develop your knowledge around the crisp algorithm. And this is sort of one of the frameworks at the Royal College has, um, provided I had to look at this and I tweaked it, um, slightly to make it, I suppose personal to me, um, and to give me prompt that I think that I found to be useful during the interview. So as a general structure, um, it's a bit more than just your a t e. I know when you when you've been practicing, most people would, you know, describe the clinical, um, interview as just an a t e sort of a ski style, um uh, interview process. But it's it's a bit more than that, and the interviewers are looking to see how well rounded you are and your your broader knowledge of clinical assessment of an unwell patient. And they're also looking to see how structured you can. You can provide your answers during the interview as well. So when you're presented with your, um, your scenario, you'll obviously undertake your immediate management. This is your your A T e structure, so you'll go through the airway breathing circulation, um, dysfunction of CNS and an exposure. So that would be the first sort of, uh, section of of your response. Um, soon after that, you then need to demonstrate that you're trying to gather as much information to help you diagnose and manage this patient. And this includes looking at things like drug charts, uh, news charts as well as the operative notes. If it's if it's a post operative patient, um, as well as any other available results as well. Bloods, uh, images and I think if you take a step back and you, you know, forget that it's an interview. These are all things that you would do naturally anyway, So it shouldn't come as a surprise that, um this forms part of the process of assessing a critically and well patient. Once you've gathered as much information and you've examined the patient and you, you're starting to have an idea about what's going on, then you need to make a decision about whether this patient is stable and they potentially need further definitive management. Often this is theater or if the patient is is stable. And, um, you know, you can sort of do certain things to to make sure that you keep an eye on them and essentially implement a daily management plan. If the patient is unstable, Uh, naturally, you would want to optimize and escalate this so you would take bloods. You would take any, uh, imaging if you need be. And you would discuss this patient with the immediate team as well as the surrounding M D T team as well, because I think it's important. These are sort of one of the buzzwords that you have to mention, I suppose, with any sort of medical talk, you know, you're you're looking after this patient. Yes, immediately by yourself, but ultimately to provide definitive management. This requires an M. D. T. Approach. So this would require discussion with I t u and h D you if the patient is really in? Well, uh, the theater coordinators and the C part team as well as well as your immediate seniors. So your registrar and your consultant, if if the patient as well. And this does come up sometimes as a, um, a curveball type of question. So the interview could say to you Fine. Okay. You've been called to see a patient who's in a lot of pain. Um, but they are otherwise Well, how would you manage this patient? Um, so, you know, you go to the patient, you still assess them, but very briefly, you still do your A t e assessment. But what they're trying to get at is your knowledge of this daily management plan, which most people don't quite know. So this list of things here is what you would usually go through on your morning more ground. So on a post operative patient when you see the patient in the morning, you have a look to see if they've had any X rays or bloods. Um, if you need to discuss any complications, you can discuss them. Make sure you get nutritionists involved. Um, you have a look at the fluid charts as well in the morning Oral intake. Is the pain management optimized? Are they mobilizing post operatively? You know, ear as protocol. Um, do they have any drains or tubes in situ? Um, all of these of holistic things you can discuss if you think that your patient is well enough otherwise, the more often than not the patient is unwell. And you have to assess them fine. By the way, if you have any questions about this, please add them to the chat as well, and I'll try and address them as I go along. Fine. So now focusing specifically on how to structure your answer. So this this is down to personal preference, I guess, Um, for me, this is what I found to be the most natural. The most structured way to, you know, answer a question in a composed and logical manner. It includes the, you know, aspects of the Chris Protocol. So your immediate management is still on there. Your, uh, full patient assessment and your investigations and definitive management are all still on there. But it also includes other things as well, which just help to round off your answer and impress the interviewer to demonstrate that you you are composed. You're thinking about the answer, Um, and your, I suppose, generally taking a taking a step back to have a take a broader look at the patient before you answer, um so very quickly. Usually the interview will give you a scenario so it could be a patient who's come back from theater. It could be a few hours after theater. It could be a few days after theater there and well, and the nurse has called you to the war to come and come and assess the patient. Um, it can be tempting to, um, start off by, you know, reading off your A t e assessment, and although this isn't necessarily wrong, you're still sort of going in the right direction. It's often better to set the scene and signpost and get those early marks as soon as you can. So this is why I've added an opening statement because you want to show that you Yes, you know that you'll have to ultimately undertake an 80 assessment. But overall, what? What are the The key things that you'll that you want to sign posts within your answer, Uh, in the 1st 30 seconds, Because this is an opportunity for you to take control of the interview and then give you sort of strong. The interviewers can relax. They know that. Okay, fine. We've got a candidate here who has done this before. They're very confident they know what they're doing. Once you've ruled off your opening statement, which is chock full of buzzwords, you then initiate your, um, your eight e assessment. Now, I think at this stage, it's important to remember that your your interview is not actually like an Noski. I think you've got three minutes to to answer your question, um, as a whole. So you need to be able to thoroughly but succinctly give out all of your points, Um, without losing any marks. So this requires a lot of practice. I think most people would, um I'm getting I'm getting to the example of the opening statement in the next slide. Um, so most people would, um, you know would say Okay, fine. You know, go through your A t e, but take your time. I think it's important. Remember, you got three minutes, so try and go through it as quickly as you can. And then, as we said, full patient management investigations and definitive management Perfect. So if we go through an example scenario, you know, you've been called to the, uh, to the ward to assess a patient who's post operative. They've had a small bowel anastomosis in theater. But the patient tells you that this patient has a low BP. The question is usually, how would you assess this patient? How would you examine and manage this patient? What would you do in this scenario? And I think you know, having a look at this, I think you you should automatically start to be wondering. Okay, fine. What? What actually could be wrong with this patient? You should start to have some ideas. So, as I said before, don't jump straight into your a t e, um, signpost early. And what I find to be useful. In example, opening statement. Um that is well around. It is one that demonstrates that you you recognize that this patient isn't well. So this patient, you literally have to say it. Spell it out for the interviewer, this patient is critically and well, and I would want to assess them immediately. So this if you have a look at your your score ing matrix, you're marked on your ability to prioritize you stating that this patient is in well and you want to go see them straight away is automatically saying to interview. Okay, fine. I'm concerned about this patient. I need to go see them straight away. Next, you can then demonstrate that you you were a forward thinker. So often you have you have been bleeped by the nurse. If you're elsewhere, or the nurse would have given you a phone call, you can ask the nurse over the phone or anyone else who calls you to get the drug chart ready the fluid chart and the operative notes. This is sign posting and demonstrating to the interview of that. Okay, I'm already thinking about what sort of information I'm going to need to assess this patient. And then, obviously, when you get to the patient's bedside. You want to then real out your buzzword. So I'm going to assess when to escalate the crisp protocol, um, and assess this patient in an 80 fashion. So, you know, this will take you 20 seconds, 15 to 20 seconds to say this, but overall, already, you already mentioned that this is a critically and well patient. Um, this is when you want to go see straightaway. You want the relevant documentation there available for you to use and your sin posting that you're going to use the Chris Protocol following an 80 management. So already you're you're you're you're off to a good start there. Okay, Once, once you've done that, then you want to quickly assess assess the patient. So, as I said earlier on, you want to try and get this done and out of the way as soon as possible. So, airway, you would literally just speak to the patient. If the patient is speaking back to you, the Airways patent and you move on to breathing and you know that's literally one sentence. Don't waste too much time. You may get some scenarios where, um, the patient could be struggling to breathe or they could be hypoxic. At this point, it's, You know, I think you have to tailor this framework to whatever clinical scenario that you get. If you're worried that the patient has airway compromise, then you would mention that you would, um, start airway maneuvers. Use a way adjunct. Um, start this patient on oxygen. Um, so although the framework is fairly generic, you still need to tailor it slightly to whatever clinical scenario you're you're provided in the interview, breathing once again. So the way I like sort of like to structure each of these sections is I'm at the bedside. First, I want to have a look at the observations and then examine the patient and then intervene. So observations first fine for breathing is the respirator and the SATs. Is that available for me to have a look at good once? That's of, of course, that information I can just quickly examine the patient's of breathing. You just palpate Percocet auscultate. And then what do I need to do to intervene? It depends on what I find. So, you know, in most patient's, uh, this patient is hypertensive. Um, depending on what their saturating. I could start them on high flow oxygen for and one would be the mask or get a chest X ray as well, in case they have a P. Um, well, I suppose for a pe you then get a CT pa. But there could be other respiratory pathologies that you could rule out at this point. If you're worried that they are hypoxic or actually do have to have a PE, then you can get an A B G as well. So as an example, A very quick statement, I would say, Um, I would recheck this patient's respirator and oxygen saturations for palpating per cussing and auscultate in the chest. Don't be tempted to describe every little thing that you would do. I think the interview just wants to know What would you do? Succinctly. So you want to pop A You wanna pick us and you want to auscultate um, I would start this patient on high flow oxygen for a non would be the mask and get a chest X ray and a B G if needed. And that will literally be it for me, for C for circulation Once again. Same structures before obs examine. Intervene. So, you know, for circulation the main things we're worried about this patient is hypertensive. So they could be human dynamically unstable. So I want to check the heart rate, the BP and the cap refill. Those are the main three things that you want to check for for circulation. Uh, when you examine, you examine the peripheries are the clammy um they warm, uh, fluid status looking at skin turgor and mucous membranes pulses. And you would oscal take the heart as well. And that's done. That's that's your examination. Done. Uh, for interventions, um, and investigations. You would get an e c G obtain IV access, blood's fluids, transfusion if need be. And don't forget the capital. This is something I always used to forget. A catheter allows you to monitor this patient's fluid output, So it's quite an important especially for this, uh, for this scenario. So this this circulation I find for most scenarios is usually the chunkiest bit because there's a lot going on that you. So if you need to justify, um at this point, So I suppose for this for this patient, worry about Coumadin McDonough compromise. So I want to make sure that I I sign post that I want to do a fluid status assessment by check by checking all the observations, Um, as well as the skin texture and mucous membranes. Um, you listen to the heart. Although this is a very little significance, it's still important that you still mention it. Ultimately, you want to get an e c g for this patient. But more importantly, you want to establish IV access and you know buzzwords again. IV access in both anti cubital fossa. See, um, now you take a step back and you think, OK, fine. What would I do in what order? Once you've got IV access, the next natural thing is to get bloods. You usually wouldn't start fluids before getting blood. So you get bloods after you get IV access, and you haven't think about the scenario. So what bloods is this patient going to need? Um, generally full blood, country and all profile and crp won't really. You know, you can't go far wrong If you mentioned those three. I think those are sort of basic baseline. Um, and then you think more carefully about what sort of information you what you think is going on in the background. So if this patient has, um, skin, bowel or an anastomotic leak there lactate could be raised raised as well. This patient has a low BP. Um, they likely have peripheral hyperperfusion so elected would be raised as well. So if BBg wouldn't be a bad chat at this point, If you're worried about a bleed, you can also get HB from a V B G as well, so that immediately gives you instant feedback something that you can use. Um, finally, you're planning for planning ahead once again. So if ultimately there is a bleed or if there is a leak, this patient may potentially need to go to theater. So a cross match, Um, if they need urgent transfusion, if they're in shock, then you may also consider a massive hemorrhage protocol as well. And once again, as I said, make sure that this patient is catheterized. Okay, so you're moving on to D um uh dysfunction of CNS. Once again, obs examined intervene. So you check a blood glucose glucose at this stage, you assess the pupils to see whether they are, um, equal reactive to light and accommodation and you check the G c s s G G C s. If you're worried you can get a CT head. Um, but generally, I I suppose for this for this scenario, that necessarily would be indicated. Um, once again, very brief sentence. I would then assess the patient's conscious level using GCS scale. I would request the CT head if this is less than 13. So have a look at your CT head Indications, um, and then assess the pupils and the glucose level as well. And that's that's disability. Done. Finally exposure. Um, obs. You want to measure the temperature you want to examine in the head to toe fashion? You want to have closely have a look at the surgical sites. Are they infected? Um, you want to have a look at the abdomen? Is it soft or the parrot net Ick. Um, and the carbs as well. Do you think this patient may have a, um, a DVT? So in your statement, you want to say that you would you would expose this patient whilst maintaining dignity and Norma therm. Eah. Um, I think often when you're under stress and your anxious in the interview, it's quite. You know, it's quite easy to forget all of these holistic things that make you a well rounded trainee. You know, you're exposed to the patient, but you don't want them to get cold. You want to make sure that they are fully covered. Um, And then you would look at the surgical sites. You would examine the abdomen. If need be. You would examine the calves to make sure that they are not tense, that the patient doesn't have a DVT examine for PR bleeding. This is an, uh, an abdominal scenario. So you never forget to examine for PR bleeding as well or rashes. Um, and finally, you would take a temperature as well off the patient. Okay, so you've finished your a t e. Which should take you roughly two minutes. 2.5 minutes. Um, you then want to move on to gathering as much information as possible. So, you know, you would say to the interview. Okay, fine. Um, as long as this patient is stable, I would want to take a focused history if they're able to talk. Um, otherwise, I would also have a look at the drug chart. Are they on any medications that could be making them hypertensive. Um, have a look at the operative notes. Were there any complications? Was was it a difficult closure? Difficult anastomosis. What is the risk of an anastomotic leak? Um, was the patient Susie, Could they be bleeding? All of this information you can get from an op from an ob no. Have a look at the new start as well. You know what? What was their new score? A few hours, you know, from now what was the new school score yesterday? Um, are they trending down? Was are they trending upwards? Is this, um uh, you know, an insidious thing as it just as it only just occurred. All all of this. All of this documentation really helps you get a proper picture of what's going on with the patient. And then, finally, as you would do normally, you'd have a look at any, Um, so let's go back. You have a look at any period operative imaging, um, and blood results as well as this can give you information about what could be going on and how to best manage the how to best manage the patient, which leads you on two investigations, so you know, once again always ensure to structure your answer. So when you're talking about investigations, I think as you go through your 80 you'll find that naturally you mentioned most of your bedside investigations. So you would do your your blood gas. You would check your respirator or your BP. So most of things, most of these things the good thing about the structure is that most of these things you would have mentioned anyway, um, which only really leaves your radiological and definitive investigations. So, um, a common statement, one that I sort of prepared for most scenarios because I knew I'd have mentioned most of these investigations during my A t e was you would state that you've requested the, uh, this word preliminary studies investigations at the bedside. And then you now want to request your definitive investigations, and these are specific to the scenario itself. So in this patient, if you're worried about a perforation, you would get an abdominal X ray. Um, or you would get a CT abdomen, pelvis to have a look for an anastomotic leak or a small bleed. Once that is done, Um, you then focus on your definitive management. So finally, with all this information that you've gathered, what is actually going on with the patient, and I think it's important to try and state what you think is going on, Uh, you don't have to say it's one thing you could say. Okay, fine. My suspicion often mathematic leak is quite high because this patient is hypertensive. They look to be in shock. It could be an, uh, intraabdominal bleed because their postoperative, they're in shock and they're hypertensive. Um, it could also be cardiogenic shock as well. Uh, this patient could be having an m. I and they are in shock as a result. So start to have a think about what you think of what you think could be going on and mention your differentials as well. So once you have an idea, what what are you going to do? Does this patient need to go to theater or could you manage them on the ward often? Um, and I think this scenario is alluding to the fact that this patient likely has an anastomotic leak or an intra abdominal bleeds. So this patient may need to go to theater if they need to go to theater. Um, common things. So keep them. Keep them near by mouth to get your group and save document the last oral intake. Consent them if they're alert. Uh, mark them, if appropriate. If it's a limb, for example, um, and book them for theater. Likely, this patient is very and well, so you would book them into Seaport Theater. And don't forget to escalate. I think ultimately, Although it may seem as though you're managing this patient by yourself, you need to discuss this patient with your registrar and your consultant. You know, you you you define your management plan, you tell them what you're hoping to do and they would be in a position to give you advice about definitive management. This also includes discussing it with the wider team as well. So you h d you and I t u teams. This patient may need ionotropic support post operatively. So it's good to book HD you bed and think ahead. Uh, discuss this with your anesthetist and the theater coordinators as well, as well as the seaport team. Okay, so, uh, to summarize everything I've just mentioned in the previous slide a good response would be, um Ok, find my differentials. Are this hypothalamic shock from an intra abdominal bleed? Septic shock from Anastomotic League or cardiogenic shock, which could be from an M i or or an embolus? If the Bishop patient continues to deteriorate, then I would optimize them for theater by making them know by mouth, documenting the last oral intake before consenting and booking them for Seaport theater. I would then immediately escalate this patient to my registrar in Consultant to demonstrate the interviewers that, you know you are a safe trainee and you ensure that you're escalating early to try and make sure this patient is managed as early as possible. Immediate management. Um, so what can you do at the bedside to stabilize them? Obviously we've given we've given them fluids. If he doesn't respond, we can give him bloods as well. If you're worried about sepsis, you can start him on antibiotics and start the sepsis. Six, Um, if the if you're worried about cardiogenic shock and you're worried that the electrolytes could be deranged, Um, there are ways in which you can manage this as well. Ultimately, you want to discuss this with your seniors directly as well as the M D T team as, um, to ensure that this patient goes to theater for an exploratory laparotomy. And before I move on, I think it's important to when you're describing your definitive management, try and say what you think this patient should have. So if this patient has an intra abdominal bleed, they will likely need an exploratory laparotomy. If the patient you know, if it was a different, um, different scenario and the patient was an obstruction, this patient needs a catheter. Uh, if you can't get a Catherine, then you tell the urology team and they may need a suprapubic catheter. So, uh, every, uh, when you're describing your your management, try and explicitly say what you you feel this patient should have. Okay, so once that's done, you'd have pretty much answered the question. Um, and you usually have roughly two minutes or one minute, um, within which they can ask you a follow up question. Now, follow up questions are usually related to the crisp scenario that they've given you, so they could then ask you Fine. OK, um, you've given this patient fluids, but they're not responding. Um, What else would you do so often? If you find you, you're you're you're at this stage. It's good because you've answered one question and they're likely just trying to push you more to allow you to get more points and demonstrate how good you are. So we've got a patient here who has not really responded to fluids. What are we worried about? This patient is likely losing fluid volume somewhere, so there's likely to be a bleed. If this patient is a non responder, then your main concern is that of hemorrhage. So you want to escalate the you want to escalate the massive hemorrhage protocol? Um, so, yeah, you pretty much say that you would transfuse this patient, uh, to try and stabilize them as, uh, as soon as possible. Um, you would give them o negative blood as soon as possible, but ultimately they would need to go to theater to stop the bleeding. And you know many of the things that we mentioned before. So discussing this with the m d t. You know, mdt approach with the surgical team when you suggest theater coordinator and intensive care team. Okay, so that's sort of the overall structure. Um, and I think, you know, if you if you can break down into find when I when I get my scenario, I want to first, um, provide an opening statement, which allows me to sign post what I'm going to do. Then I'll quickly go through my a t e Once my a t e is done, I want to have a look at any surrounding documentation and results to get as much information as possible. If there are any outstanding investigations, I can request them at that point. And then I want to discuss and have a think about what's going on with the patient before planning definitive management. Now you're I think you know some of these points I've mentioned before. So it's important to remember that your interview, your clinical station isn't really an Oscar per se because you don't have as much time. You've got three minutes, so you really do need to be succinct. Your your responses for each section need to be sort of 1 to 2 sentence lines. Um, some sections will require longer responses, but if you can keep your overall answer within three minutes, you're doing quite well now. So this is this is quite an interesting point. Um, some, uh, when I when I was preparing for my interview, Um, there was some advice from seniors who had said that if the if you stop naturally. So let's say you've gone through your a t e and you stop before moving onto your, um, I don't know your your your management plan. For example, if the interviewer interjects and asks you what you would do next, this counts as prompting, and you you often get marked down for prompting. So what I would recommend is that without rushing and still maintaining a good pace, just go through your answer from start to finish. And this is good because it allows you to keep control of the answer. Um, it shows that you're continuously thinking about what you're going to do next. If you stop, I guess it, I guess, to the interviewer, it may look as though you're stuck and need a bit more help, but I suppose if you just go through your answer from start to finish, um, it's a bit more smooth, and it just means you can get as many marks as possible. Um, And as you know, this goes without saying try and keep your answers structured, and it's all about structure. I think whenever you start to feel flustered and you feel like you're forgetting something, try and find a structure that you can fall back on that is useful to you. It doesn't have to. It doesn't have to be anything that is, you know, common or out there. Um, just try and fall back on a structure that you that you're comfortable with. Okay. So are you allowed to write down notes or keywords before you talk? Um Mm. I don't know. Actually, I don't I don't think so. Um, but I think you also have to consider that you've got three minutes. And how much time are you going to spend writing down notes? So theoretically, you probably could, I'd imagine Probably not, because they try and keep the interview fair. And I suppose from the interviewers perspective, they don't really know what you're writing down. And then for you to have then have to show them that you're writing down notes. It's It's just very time consuming. So simple answer to that is I don't think so. I don't think I probably probably not. I would say, um, you can do But it's also, you know, it's also taking away from taking time away from your your your answer. Essentially fine. So there's sort of general tips, um, one last little plug following my interview myself and a few registrars and other court trainees as well have started to develop a resource that we hope will be useful to applicants for this year and, uh, many years going forward. Um, I found that the CST interview interview book was good. Um, but I'm quite lazy in the sense that I prefer I much prefer to watch and listen to something. So, you know, audio visual resources are are the way to go for me personally, and this is what I you know, I found other other candidates felt the same way, too. So what we've done is we've we've essentially created a video bank of, um, particular, uh, scenarios that often come up, um, divided into your two stations for your management and clinical interview stations as well. Um, this is still an ongoing project. We have some free videos on the website as well. Um, and We're still collecting feedback and hopefully trying to to to develop the resource. So if if you you know, if you're curious and want to find out more, then definitely have a look at it. Obviously, I'm I'm slightly biased because I'm involved, but, um, I I think it's a pretty good resource. So definitely have a look and leave feedback. If you do decide to, um, to have a look as well, and I think that is it. So if we have more questions is there an email? Yes. I think Frayer will share my email. Or I can just share my email in the chat. Uh, do you mind, Freya? Actually, my email in the trap. Yeah. Please do. Please check your email. That's great. If you are going to be contacted. Perfect. Always happy to be contacted, right? There's a couple more questions. Mhm. Um, first of all, thank you so much, Gary k. I think we can all agree that that was excellent and really, really useful for preparing for the interview. Um, I've had a look at your resource myself, and it's brilliant. Um, so I would urge everyone to take a look. Um, so Let's take a couple of minutes for questions. So there's a question here that says, Just to clarify, It's three minutes for a B, C D E plus def. Definitive management with two minutes for the additional questions. So I think just to be clear, this this isn't a, um a strict sort of, um, you know, strict time division, I guess. Um, a good answer. I, in my opinion, is roughly 33 to 4 minutes. Um, you can take longer. But this then doesn't allow the interviewer to ask you more questions. And speaking for five minutes is quite a long time to be talking. So you're sort of trying to balance, not boring the interviewer trying to get your answer out as as quickly as you can and as simply as you can. So, for me, I felt three minutes was a good amount of time to talk through your your A T e and your management plan. We're sort of one minute and a half to two minutes of additional questions, and I think that makes for a fairly rounded and balanced interview, in my opinion, so you know, it's it's it's not. It's not a set timeline. It's not a set time time restriction you can spend as long as you want answering one question if you'd like.