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I'm just gonna introduce our speaker. Our speaker is Mr Jack Clark. Jack is a orthopedic registrar working in Scotland who's kindly given up his time to give us a session on the CST interview focusing on the clinical section. So, Jack, I'm going to mute my camera and my microphone and leave it to you and I'll pop up. People ask questions, and I'll ask them from the chat. Sure. Good evening, everyone. Yes. So, uh, without much further introduction, Uh um, as I say, I'm currently working in the west of Scotland as a, uh, sort of Reg level doctor. And I'd like to just sort of share a bit about both my experience with the core training application, All although that was a couple of years ago. And then from there, we'll go through a few sort of common clinical scenarios that you might expect to sort of encounter in trauma and orthopedics. So I don't know. Is that working? Can you, uh, see my see my slides at all? Yeah, we can see it. Lovely. Right. Okay. So obviously, this is the, uh, 80 less trauma orthopedic scenarios. So first of all, Yeah. So that's changing is it? You can see my new slide here? Yep. Cool. So just before we start, um, I don't know if any of you sort of keep an eye on sort of literature surrounding interviews, things like this. I thought this was quite an interesting paper about the influence of time and date on surgical outcome. Um, in which, um, as you can see, you know, that there is a little bit of a difference at the between influences of time and date on on your interview and what you can reasonably expect from that. So if you have a chance, just have a look at that article and see if it influences your sort of decision making as to whether to go for an early interview, get out of the way or go for a later interview and have more time to prepare. But at the same time, sometimes there's a little bit of a degree of fatigue for your your assessors. So, um, I would say I went for quite a late on interview. Um, ultimately when I got my job for ccs tea, But for everyone, there's a sort of, um, preference for that. So these books are really useful. I'm sure some of you have encountered these before. And if if you haven't already encountered them uh, definitely go for the Picard book on the left and the middle one, the court surgery interview book as well I use these to during my interview. Um, time and I found both of them really, really useful not only for just trying to figure out what a good answer would be or the kind of answer and the and the way to show. Take them and frameworks as well for thinking about your answers, but also for the practice questions that are in there, which I found absolutely invaluable times may have moved on since I was a court trainee. I've I'll talk about that a bit later, what with the not face to face interview, etcetera. But I I still found the material, and it's really, really useful. Even if this is predominantly on teams now. So a little bit about me. So I'm a post CST clinical fellow working as a registrar in orthopedics in the west of Scotland. Um, I finished my core training in July in 2022 just gone, and I'm applying for ST three orthopedics. This year I applied to CST twice applied as a rather impressionable FY to 2018 2019. Um, and as you can see, that that didn't exactly work out particularly well, um, for for a few reasons. Really? Um, one of which was that at the time I think I had really underestimated the level of competition. But I think more to the point was the fact that I've never really done a specialty interview before and knowing what to expect and knowing how to frame my answers. And, um uh, and knowing how to appear as a good trainee to the examiners was something that I, uh, really didn't have at that time. And with that sort of experience, I then applied a second time around and, you know, had a much better result from that When I both went out to flush out my portfolio relative to the self assessment, which obviously all of you will will have done, um uh, along with, you know, various other sort of considerations, which those two books that I mentioned there I found really, really useful for framing answers and thinking like a trainee and thinking like a successful applicant. So I got my first choice job in the West of Scotland, which comprised 12 months of orthopedics and 12 months of general surgery. Unfortunately, as you can probably tell from the times, this directly ran into the covid 19 pandemic, so I didn't see perhaps as much orthopedics as I'd hoped to. But you know, now we live in a post covid world, and it's, um, it's sort of had its own impact on training, etcetera. But I found it to be, you know, a very good time in the West of Scotland. Shameless plug for West of Scotland. I know, but, uh, there's a huge amount of trauma. There's a good amount of operating. Um, so, you know, in terms of my recommendation for the CST experience in in sort of Scottish Dean Aries I I thoroughly recommend it, and I'm the current orthopedic lead for minor BLEEP. And I'm currently sort of trying to flesh out that part. The site, um, for, uh, sort of helping with education of orthopedic side of things. So you guys are definitely going to be the experts on how to apply for CST, and I'm sorry to hear about including the MSRA into the application this year, and I think that's really mean and just another hoop to jump through. I understand that the interviews between the ninth and 22nd of March, so you've still got a good amount of time to prepare. Still not face to face on Microsoft teams. That's where my interview experience was obviously very different, because I had to go down to London twice. And, um, obviously that had a much different kind of format. And in some ways I think that was a much easier time to come across well to the examiners than on Microsoft teams. But this is the world we live in. Um, at the time that had a dedicated portfolio station. So the interviews themselves were 30 minutes long, with three stations each 10 minutes. So a management station you started with which it's pretty much unchanged here, actually. So it was almost always a leadership presentation that you prepared beforehand, um, which usually involved how some element of leadership made you an effective trainee and you could have sort of relate that to your own personal experiences. And that was followed by a two minute sort of, um, questioning from your examiners, which would ask either to clarify things or for other sort of more specific aspects of leadership. As you you bring it in and you could you could create more points for yourself there if you sort of, um, led those questions for the examiners. And five minutes later, for the last five minutes, you got a sort of ethical, professional personal dilemma. So that's a That's a usual, fairly classic kind of S J T type question where you know your your consultants drunk or you're dealing with a difficult colleague or you're trying to publish something. But your senior author wants to put their friend on as a second author and how to think about that. And again, you know, that's something that you can develop by speaking to your colleagues by, uh, the sort of resources that I've mentioned there. And I'm sure there's a number any number of of other resources that either you have to pay for is the sort of subscription type thing. Or, um, you know, just sort of comes with your own professional experience and, to be honest, a good deal of common sense. Um but enough about S J t questions because I know that that was a big part of the MSRA. And, you know, that was that was not great. The clinical station, um, you know, is is was sort of the last part of my interview. And I think that was a really good way around because the presentation side of things meant you could just memorize all your stuff and then just get it down. I forget about it for the rest of the interview. Um, the clinical station I'll obviously talk about in a little bit more detail. Um, because, uh, that's the focus of this. And it's something that I think causes a good degree of anxiety for a lot of applicants. But I think that the key part of it really is to just know your basics. Just rattle them off, be nice, confident and clear, and try not to freeze up. I know it's a really easy thing to say, but, um, at the end of the day, a lot of this is stuff that you will have been doing for, you know, a number of years now and knowing how to present it and what you're going to do and having sort of almost a capacity from that practice of being able to think ahead. It is something that I definitely did my second time around that I found really effective. So I mean, it does show that sort of things are getting a little bit more competitive. And I say this from a position of, um, you know, this is data up to the year before last 2 2021 things are getting a bit more competitive and the posts are arguably decreasing. I'm not sure what things are like this year, but I do know that applications are are increasing for for one reason or another, which, you know, like it or not, it's probably the reason why they brought in the MSR a as a a sort of secondary way of assessing you. But things are getting more competitive, So merely the chance that you're actually here, you're coming to the seminars. Will, you know, I hope, give you an edge over the rest of your competitors who, you know, some of them will be a bit like me when I was in FY two and just sort of turning up, not quite knowing what to expect. And I hope that during the course of these seminars, we can give you a bit of a, um, an idea of what to expect. General tips for the interviews, you know, it is a long process applications. I'd be lying if I said it didn't cause me a good degree of anxiety. Uh, not only, you know back then, but also now for ST three, it can take months or even years of preparation. Don't be daunted by that. You know, you guys have been preparing for this in in a way by wanting to do surgery in a way that's different to just sitting down and thinking, right? I'm going to go and study pancreatitis or or, um, you know, uh, cholecystitis gall stone disease or whatever it goes without saying. I mean, a lot of guys, uh, will change placements next month in a week's time. Um, and that will lead itself to a whole new row to so arrange swaps early. Arrange them Now, find your colleagues, find someone who can swap with you, you know, and and find a time that suits you to have that interview and and arrange swaps early and make sure you get a good amount of leave and study. Leave in advance so you can be in that race. Right state of mind. Nobody wants to go and do a specialty interview after having doing done a run of nights, For instance, Um, and I've been there, too, and that that was that was a really bad idea, so I wouldn't recommend that at all. Any surgical department is probably going to have a fair idea of what to expect for course. Surgical training, whether it's plastics or e n. T or or orthopedics or general surgery. So getting in touch with your educational supervisors getting in touch with friendly Reg is getting in touch with, um, any number of consultants they're involved in education will be will be really helpful. But for the most part, general surgery is a pretty solid choice. So if you know any friendly general, surgeons obviously just send them an email. Any former educational supervisors, Uh, because the the key to success really is practice, practice, practice. So when it's on the day, you're not daunted by the fact that you're sitting there in front of a camera potentially freezing up. Okay. And on the subject of revising with other applicants when I back in 2020 when it was still face to face before covid really hit us, uh, I spent about 4 to 6 weeks before interviews, Um, which I remember. We're sort of late January early February. Um, I sort of learned about clinical content management content, and and and as I say, those books I found sort of really helpful for that, Um, N h s political issues is a little bit of a funny one. Sometimes the BMJ works quite well. To be honest, these days, the junior doctor read, It seems to be right on the case most of the time and preparing the answers for this and I I'm one of those people that just sort of writes out a big list of potential questions and potential answers because there are some ones that they're just going to ask you. So if you've got a good answer, why not learn it? And then you can relax when you hear the question. I think this is a gift and then go for it. Two weeks before interviews, I did lots of mock interviews with my colleagues by which I mean both registrars and also prospective people applying. Um, and I actually found that quite useful to plug gaps in my knowledge because some people would know things that I did not, and vice versa. And then, you know, a day or two before interviews, I just thought, Right, that's it. Time to relax, pack my bag, make sure you know my suits nice and, um, clean. And, uh, I'm nice and clean and, you know, um, have all my travel to London sorted out and then, you know, day before the interview, you don't want to cram. You don't want to stress, but it's absolutely up to you. You got to find a system that works for you. Um, were all people have done, uh, I hope medical degrees and gone through that cycle of assessment. Uh, some of you. Well, you all have gone through the MSRA, which I've never done. But it's just another postgraduate exam, just like the MRCS, which is obviously something requires a good deal of preparation as well. And for parts like the part B exam, that's something that I found really helpful. Practicing with other applicants. But it's absolutely up to you if you feel like that's something that can make you incredibly anxious. And it's something that you want to practice either by yourself or with more senior colleagues that can provide much more of a learned opinion, then, you know, go for it. It depends on your learning style. Um, so what I was saying was basically like in things like the portfolio station, there's common questions and there's essential answers that you need to know, and they'll be along the lines of this. So why do you want to do this? Why do you want to do course? Surgical training? Why do you want to be a surgeon? Tell us about yourself, Your CB your career. So far, no matter what spin they put on it, they're all basically asking the same thing. Which is Sell yourself and what have you done so far to prepare for a career in this specialty? And I know that we're going through the clinical questions, but things like the camp format, the clinical, academic management and personal format it's a great way to structure these sorts of answers and things that really let you talk about your biggest achievements or your your strengths or what makes you the best candidate out of everybody, it's It's really a good good question to have, because that allows you to draw the interviewers to something that makes you special. Makes you stand out something that, um, you know, because you're all intelligent people and you're all people that have done things that are very impressive and knowing how to sell that to the rest of the panel. Who even if they're pretending they're not going to interact or react, they are impressed. Um, even if they act all PPO face during the interviews, that's another thing that can throw you off. And it's another reason why to practice so main strengths and weaknesses. What what could you improve weakness? Questions are always a little bit of a difficult one, Um, but I'm sure you have seminars that that talk about this in more detail. But essentially something that you describe, which is also something that you're aware of and trying to improve always comes off well, Other things to consider. I was hoping that that would work, but that's Han solo from Star Wars. Don't get cocky. You can smile, be confident, but don't get cocky. You don't sort of try and second guess the examiners or even argue with them, which I've heard someone that did. It's always a good thing to have a recent paper to talk about, and you can talk to your educational supervisor, your consultant about this, Um, and you know that feeds into the commitment to specialty. It shows you've done your work. It shows you've given your potential career. Some thought beyond what happens at work. The hum drum of the on call and you had a look at sort of more contemporary literature, and you're a bit more than just a name on a rotor. Be honest and genuine with the answers. Be insightful. Um, it's it's It's a difficult line sometimes to tread, especially if you're not feeling very comfortable during that interview. But, um, being compassionate, being patient, focus making patient safety your first priority. Um, sometimes it's just the way you say it. So, for instance, um, I've made this more surgically minded. But in orthopedics for the S D three interview, there's a station where we have to basically do a prioritization type station so a list of patient's with various issues that we then have to organize into the 1st, 2nd or third patient's on the list. And you know, some patient's just can't be done because there's not time or there's no equipment and saying in your interview, Cancel the lack Collie can come across as a little bit, um, impersonal, detached. Um, so saying something that shows that you're not that kind of person, that you're someone who knows that there's a patient attached to that gallbladder, Um, can can go a long way for this. But as with all things, it's a question of time. So, um, being compassionate, being patient, focused, making patient safety your first priority. And that's something that feeds well into the clinical scenarios as well. So remember, they're not looking for a consultant surgeon. They're looking for someone who wants to be trained. Usually, the clinical station will take the form of five minutes of a sick patient seen an E. D. R on the ward, and you talk about your initial management. You talk about your A to EU talk about your a. T. L s primary survey. You talk about what you're going to do when you walk into that room and you see that patient because pretend that there's no one else who will look after them. Okay? Generally, it's quite easy to talk a lot for these five minutes, and sometimes it's difficult to not get bogged down in your initial assessment of them. They're a to eat, Um, and the the examiners. We usually know when to move you on. It's usually pretty obvious when you're confident you know your stuff and then examine. All right, right, Right. Okay, okay. Clear. You know, because that's what happened to me and then organizing appropriate investigations, etcetera went to escalate to a senior when to involve other specialties are all things that sometimes you can say without being prompted. But sometimes, you know you will be prompted. And don't get put off by that for orthopedic specific things. It's usually going to be, um, some sort of trauma scenario, like an A t l s type scenario, and then any number of orthopedic emergencies, which, without giving too much away, um, you know, we can talk a little bit more about this, but you know your big ones compartment syndrome, septic, arthritis, open fractures, Um, pulmonary emboli, postoperatively hemorrhage from wounds. Um, knowing the initial management of this and when to involve your senior is, you know, a big plus and will stand you in good stead for the interview. But specific resources for a trauma and orthopedic scenario are worth looking at. Would be things like your A t. L s advanced trauma, life support, Um, which, you know, the protocol for dealing with initial presentation is available quite widely, and would would be worth it. Read the boast guidelines or the British Orthopaedic Association. Standards for trauma are a set of guidelines that govern quite a number of orthopedic emergencies, like open fractures, compartment syndrome, and just look them up on the site. They're fantastic. They tell you exactly what to do for each step. And if you don't deviate from the both guidelines, you won't go wrong. Okay, so look them up. Really? They're great. I'm not just saying that because I have to, like, memorize them for my next interview. Anyway, um, what I'd like to do is go through some practice scenarios and, you know, it would be really nice if, um, some of you could just talk through the scenarios for me or say what you would do. And then that way it will be a lot more interactive. And you don't just have to listen to me talking. Um, So without any further ado do, we'll move into the first station. So imagine that you're at your interview and you get this piece of text and you've got a minute or two to read. The, uh, read it and then you move on to the questions in the room. Okay, so you're called to e. D. To assess a 24 year old man who has been stabbed in the right side of his chest following a fight. He's talking to you, but appears to be confused and breathless. His knife wound is three centimeters wide and approximately five centimeters below the right nipple. It looks to be clean and doesn't appear to be profusely bleeding. But looking at the observations chart, you notice that during this man's time and e d, he's becoming more and more to keep nick and tachycardic. Yeah. How would you perform your initial assessment? Anyone? Uh huh. Anyone want to shout out? Okay, so you Yeah, you could say that you would want to manage the patient. Well, you'd want to review the patient using the A. T. L s guidelines and start with an 80 approach as your initial assessment. Yep, that's that's fair enough. So Yep. So I see that a TLS guidelines Stein with a primary survey and an a two e. So, um, is there anything specific you might want to do for in terms of managing the airway side of things? Is it Is it just airway in in a two e for a T l s C spine? Yeah. So c spine. And how how are you gonna secure their C spine Until you can be sure it's it's clear. So you want to do triple and mobilization collar blocks and tape. There we are. Yeah, that's good. So thanks for that. So the rest of the A two e I won't waste time. I won't insult your intelligence, but it's essentially just the exact same thing as the 80 we we all know. So you'd want to, uh, make sure that there's monitoring that there's BP. There's BP. There's, uh, SATs probe that this guy's got ox oxygenation. You'd want to make sure. Usually 15 liters. Trauma mask. Given the history of trauma, what should you ensure is done for this patient? Ideally, before they arrived in e d. Sorry, none of you guys can can. Yeah. Trauma call. That's it. I'm sorry. None of you guys can talk. It seems, uh, seems like we're stuck on the, uh, stuck on the chat. Um, so, yeah, these guys need a trauma call, ideally to be seen in a recess bed with a full trauma team there and attending. I have seen patient's like this where they've just been in some random bed and majors, and you're the only one that's attending to them. Uh, and even after they've arrived in E. D, it is possible to put out a trauma call and arrange for them to be moved into recess. So don't be daunted if that appears to be the case, but they need to be moved over. So I think we've got pretty good, um, a pretty good grasp of that. Okay, so, no, uh, it looks like all my answers have have have sort of shared themselves, but that's okay, because no one's able to talk over this But you know we can We can talk about what these would be and that will help. Sort of with the timing. So a differential diagnosis. I'm sure you guys can tell from that sort of case history that a hemothorax or a pneumothorax would be your biggest concerns here. Because on the right side of the chest, probably not so much a cardiac tamponade. But injury to great vessels, neurovascular bundle and the ribs is is possible. Uh, the guy is getting more and more breathless. He's getting more and more tachycardic. He's got flail chest, maybe with a Pommery confusion. You haven't got any imaging yet. And you know, I always think about a diaphragmatic rupture as well. Potentially especially if there's, um, elements of that on on imaging. But right now, all we've got is a set of observations and this knife wind. So what investigations would you want to undertake in terms of labs? Yeah, So I want to get some bloods a full blood count. You Andy? Uh, crp, perhaps an amylase. Um, we want to get a lactate. We want to get, um, yeah, a coag and most likely a group. And save as Well, um, depending on how his observations go, you might want to get that across match as well. Um, yeah. So we want to get also an A B G or a V B G. And that's useful because that lets us get a bedside lactate. Um, a sort of an idea of his acid base balance ox oxygenation as well. Um, and then in terms of radiology, you know what, what good initial investigations could we do there? We could get a chest X ray, um, to to see whether there is indeed any Yeah, portable chest X ray. So that's good. You see whether there's any pneumothorax or any obvious hemothorax. In that point, you'll be able to see whether it's diaphragmatic rupture as well to see whether there's a presence of bowel within the thorax. Um, you might also be able to see whether there's, uh, any, uh, rib fractures or any evidence of flail chest as well. Pulmonary contusions. Signs for that on a chest X ray are normally a bit bit quicker. If the patient's stable enough to do it. A lot of E. D. S, as you may have seen, well, often do a CT polytrauma, if that's if that's necessary. Um, fast scans and d pls Um, well, DPL has been phased out by the fast scan. To be honest, that's quite a useful investigation to do. If you're worried about there being a potential abdominal trauma, it's a fast, portable bedside ultrasound that allows you to see whether there's intraabdominal fluid. And if that's identified, that should be assumed to be blood until otherwise fast scans usually done if the patient's too unstable to go to see T. But it is a good thing to think about, and certainly a useful thing to mention as a thing you might consider for interviews. Okay, so how would you define a massive hemothorax And what would be your initial management if you found one? Well, when you put in a chest drain for your presumed diagnosed hemothorax, if you got immediately two liters out of that drain or you got 200 mils per hour for the next 2 to 3 hours, that suggests the massive hemothorax and what that would Yeah, what that would mandate you doing would be, um, to consider yeah, massive hemorrhage protocol, uh, to consider blood products to consider um, the what we call major hemorrhage protocol and most likely get cardio thoracic involved because this guy is probably going to need theater in order to, uh, stop this source of bleeding. Um, how might you clinically determine whether this patient, an attention Nemo or a massive hemothorax? It's all in your examination that there was a sort of adage where if you had a chest X ray and it showed that there was a massive pneumothorax that that probably wasn't a good thing for you to do. Generally attention. Pneumothorax is something that should be determined clinically so hyper residents to percussion, uh, lack of expansion, air hunger and tracheal deviation away from the the yeah, trick your deviation away from where your PRESUME neuro thorax is in a massive hemothorax. You also get tricky or deviation away from where that is. But you would also get, um, dull breath sounds You might get collapsed. Um JVP I see There's a raised g JVP for the the tension pneumothorax. That's that's good because it's impairing venous. Return to the heart. It's collapsed the massive hemothorax due to hypervolemia um and, um obviously, in a hemothorax similar to sort of floor or effusion, you'd expect us all dullness to percussion. So So despite your interventions, the patient's observations, he becomes more tachypneic. He becomes more tachycardic, and he's now hypertensive, and he's continuing to be confused and is starting to fight off the staff that try and put their observations on. So what class of hemorrhagic shock is this? Do you remember that table from exams or, uh, trauma? So the patient's The key part of this is that the patient's now hypertensive, which suggests class three of hemorrhagic shock. So with this, you can expect him to have lost. Yeah, there is, um, with this you can expecting to have have lost probably about 30 to 40% of his circulating volume, and the key part is, once they become hypertensive, that's when you expect it to be Class three. Shock and Patient's are usually confused at that point, so you've infused now a liter and a half of crystalloid to try and pump up his BP, and it does so briefly when you do that and his heart rate gets less tachycardic. But once you give him his fluid challenge, his observations deteriorate again. So what you need to now consider. So the guys bleeding, isn't he? He's bleeding out of his, um, his his chest wound. So you need a more? Yeah. As you say, a more definitive management. You need to have a control or arrest of that hemorrhage. But yeah, blood transfusion or blood products is what you need to consider. And that's part of the, uh, the A T. L s protocol for, uh, massive hemorrhage or controlling hyperkalemic. Yeah. Shock. So do you know what is meant by the term permissive hypertension? No. When you have a patient that's bleeding but also dropping their BP, you have to consider a balance between giving, uh, enough resuscitation to provide a good enough BP to perfuse their vital organs. But also, um, not to have so much pressure that this burst slots promotes further bleeding. And then you get a vicious cycle. Permissive hypertension is Is that term in a nutshell? So usually we aim for about a systolic of about 90 to allow that optimum perfusion of I called vital organs while also, uh, letting you know clots form him a Stasis without an excessively high BP that promotes further bleeding. And I think Paddy's hit the nail on the head with the first clot is the best clot. That's a That's a good adage to have you decide to insert a chest strain following confirmation of hemothorax. Where should you insert this? You want to put this in the midaxillary line? Fifth intercostal space. So usually just anterior to the midaxillary line. Um, in in what is back in terms of boundary the the safe triangle where the apex is the axilla and the yeah, so fifth intercostal space and anterior to lap Dorsey. So the anterior border is the lateral border of peck major, and the posterior border becomes the, uh, sort of anterior border of latissimus dorsi with the floor formed by the fifth rib and the apex by the axilla. And generally just above the, uh, fifth intercostal space is where you'd want to put your chest drain. And if you aim up, that would be what you want to do for a tension pneumothorax. And if you aim down, that tends to be what you want to do for a hemothorax, which is what this case is. Okay, right? So this is actually where I put my answers because, um, I've never actually presented a medal before, and I really didn't know how it worked, but we'll review it again. So you're called to e D to assess blah, blah, blah. He's had a knife wound. He's getting more tachycardia can tack it, Nick. So yeah, So I think everyone nailed this one hit back on the head. You want to do your A T. L s protocol A and E airway and C spine Your breathing, Uh, with 15 liters of 0202, circulation, disability and exposure and you go back and reassess after you've done any intervention differential. Diagnosis is, as I said, but in red and yeah, So I think we hit this on the head as well. Everyone said, uh, what was needed to be done. It sounds like you've all got a very good grasp of what to do in a trauma scenario. But all of these things Blood's full blood count you and lft amylase coag group and save and in in sort female patient's. A pregnancy test can be helpful, especially if you're worried about an inter abdominal hemorrhage, because that's something inevitably that could be an issue if they're needing a laparotomy. Uh, an A B G in a V B G is useful as a bedside test to get locked oxygenation, acid base and a rough, uh, hemoglobin electrolytes And, um, again, sort of standard X rays will be useful in a trauma scenario. A pelvic X ray following your secondary survey if there's no suspicion of a pelvic injury is probably not needed. But a chest X ray for pneumothorax and hemothorax is absolutely first line would be appropriate here. And probably a polytrauma CT after that as well. Okay, so I think we, uh, hit that. Hit the nail on the head there with the massive hemothorax, um, and the tension pneumothorax and massive hemothorax as well. It sounds like everyone's, um, you know, well burst and what that is. And then this is what I was talking about with that sharp for hemorrhagic shock. So the key point here is that he gets more confused as the, uh, blood loss continues. He also becomes more and more hypertensive as his blood loss continues. Um, so again, just have a look at that and make sure that that's something that's in your head for a sort of hyperkalemic shock scenario. Chances are, if it's a trauma scenario for your clinical clinical station, it will be hyperkalemic shock. So having a good a good handle on this is very helpful. So permissive hypertension, Just like I kind of said, you know, you want to leave them a BP that ensures vital organ perfusion, but not so highest dislodged Clots are worse than bleeding. Um, and then chest trains following confirmation of hemothorax is right there. So, uh, one thing is worth saying is connecting it to a closed system and observing it for swinging or bubbling and confirming this with a chest X ray. Okay, so let's go for the second scenario, which is slightly more orthopedic related rather than just a standard trauma thing. So you're the S H o on call for orthopedics, and you're called to assess Mr Bryan, who's a 55 year old patient who's just returned from theater following an intramedullary nail for a femoral shaft fracture following a motorbike accident. He was fit and well prior to his injury, but now the ward nurse is concerned because he's confused and has reduced oxygen. Saturations Okay, So describe your approach that again, these were supposed to have snappy transitions to just, uh, pop in like that. But essentially, your approach, the initial management of this patient, an 80 we approach. But what aspects of the patient history would you want to get? More of a detail on? What things in the notes would you want to read? Yeah, that's a good one. Yes, the op note. That's what I was getting at. So the guys just come back from theater. You want to know exactly what it is they've done. You want to know how much? Uh, you know, if there are any complications that were noted, look at the anesthetic chart. The drug history. See, uh, if there are any sedative drugs that were given and that's what's causing his perfusion is, um, confusion and subsequent hyperventilation as well. Um, your assessment notes that he's now got more oxygen on board, and he's saturating at 90% by a trauma mask. He's orientated to place, but not time. You've had a look at the dressings because that's a very important thing to do for a POSTOP patient to make sure that they're not hemorrhaging, um, minimal strike through to dressings that the reaming entry point the distal locking streets as well. But you've also noticed that there's this, uh, strange rash, which, uh, appears to be on his, um his trunk is, uh is his eyes of these weird rashes and also his axilla as well. So what's your differential diagnosis here? Yeah. Yeah, good ones. Yeah, yeah, yeah. So I think some kind of thromboembolic event is, uh, is a popular one. D I c is a potential one. Hemorrhage is a possibility, but we've checked dressing sepsis. I mean, he's got a low oxygen saturations. He's got a particular rash. He's just had an operation, but it'd be quite unlikely for him to get meningococcus septicemia. But that is a possibility. Um, or, you know, some kind of barrel trauma, potentially even from his et tube. But you're on the right lines. Fat embolism. Pulmonary embolism. Should be right at the top here. So what investigations would you like to perform? Just like with any sort of ill patient you want to perform? A a sort of standard set of labs. So full blood count using these LFTs. Uh, crp might be artificially high, given they just had an operation. Um, but things like a coag would be useful to perform to check and a d dimer as well, which again might be raised following the operation. So that's a little bit of a one to take with a pinch of salt perhaps. Um, is there any radiology that you'd want to get? A chest X ray? Seems pretty obvious, but would you jump right into getting a CT p A. You might do, but a portable chest X ray considering Yeah. Fbc renal function. BBg is good. It depends on the chest X ray. You're absolutely right. So you get obviously you get IV access, as you were for your 80. We approach you get off some bloods and then your radiology, which at this point comprises the chest X ray. But considering our one of our top differentials as a pulmonary embolism, you know, potentially a CT p A. Unfortunately, he's continuing to desaturate, and that's despite, um, 15 liters of oxygen via trauma mask. And he started to remove his mask. He's getting more and more confused, and that's worsening his oxygen oxygenation. So what, you're going to do now? Yeah. An E C g is also a good idea, by the way, for those, um, for that, that last station, that's a good suggestion. It's not actually one I thought of, um but it would be useful if you're considering a pulmonary embolus. Um, so he's more He's got worsening hypoxemia. He's, um, more and more confused. You've reached maximal ward therapy. What you're gonna do now. Yeah, you got senior help. But you also need to, um yeah, I think this guy is probably going to need an escalation of his carers. And he's a fit and, well, 55 year old man, he's got a good reserve. He's got good. Um uh, you know, he's not frail at all. He's a guy that's gonna be HD you or maybe ICU candidate. So you need to escalate him. Let who do you want to let know? Yeah. I t u anyone else? Yeah. Call Ghostbusters. Good idea. Um, but more importantly, may be the consultant that's actually done the operation would probably like to know that's a good, uh, point. Actually, at what point do we escalate? So I think escalate. If you feel out of your depth escalate if you feel like this is something that requires more senior input, whether that's from a different specialty or whether it's because you're stuck or whether it's because you feel like you've reached the maximum point of which you're able to really intervene on the ward. So letting your Reg know about someone going to a higher ceiling of care is is a good idea. Um, but there's no real hard and fast rule. I would just say to let your Reg know if it's something that you feel is a serious, uh, illness. And this is obviously quite serious. If it's something that's requiring an escalation of care, if it's something that's gonna require potentially for you to palliate the patient, Um, but I would escalate to my senior once. It was obvious that all my ward based interventions we're not going to, you know, work here. So what's the pathological process behind the most likely diagnosis? And I'll give you a clue. It's not a pulmonary embolism that I'm I'm aiming towards here. Essentially, this is a station about fat embolism. So what this has done is caused a rather large blockage elsewhere in the in in the circulation. Yeah, So reaming has caused fat emboli, uh, to get into the circulation. But the fat emboli themselves cause a massive inflammatory response. So it's causing a large systemic response that is then causing a patient subsequently become unwell. So let's go through the answers again. There's the thing. And then, you know, for this an eight we approach to Chris Protocol. These are nice little buzz words to get out for your interview. So mention that you would assess this patient according to the care of the critically ill surgical patient protocol. Uh, review the anesthetic chart the operation, note the recovery notes. The drug history is a good suggestion. Um, And then, you know, I've highlighted in red the things that make up the classical triad of fat embolism syndrome of hypoxemia confusion and this particular rash as well. In the differential diagnosis, everyone chucked out is, you know, all very good. Fat embolism, pulmonary embolism right there. Yeah, hemorrhage is a possibility. Although the dressings are dry, uh, and then sort of things like stroke or m I a possible in almost every one of these sort of unwell patient scenarios. So they're always worse. Just just chucking out there. Investigations to perform. We've we've Yeah, I think we've We've hit everything that we wanted to say. They're one thing to say about the chest X ray that's useful for other causes of hypoxemia. But in fat embolism syndrome, this usually shows diffuse bilateral pulmonary infiltrates just like odds. Um, which you can get in pancreatitis or any many other critical illnesses. CT p A. Which you could get if the patient was more stable, which show ground lash changes with the global distribution. Um, A B G would normally show a type one respiratory failure. So a hypoxia without hypercapnia picture. So yeah, absolutely continue. Consider escalation of care. Involve your seniors, involve critical care for Venter, play Theresa Port. And if he continues to acutely deteriorate, then you consider a peri arrest call. Because if you're reaching the limit of what you can do in the ward, then that's absolutely appropriate. Um, so fat embolism syndrome causes a severe inflammatory response in local tissue, which causes system subsequent systemic inflammatory response with cerebral edema and arts. So that's what causes the lung dysfunction and what also causes the sort of cerebral higher function dysfunction. If you see what I mean, I I like to think of it a little bit like the pancreatitis of orthopedics, which is that it causes a severe inflammatory response that systemic but isn't necessarily due to an infection like sepsis. But it leads to a very similar kind of picture. So I thought it would be useful to talk a little bit more about fat embolism syndrome, because that's something that sometimes catches people out in interviews. But long bone fractures conservatively manage long bone fractures. Anything that involves, um, the, uh, anything that sort of involved increases the risk of of fat and bone marrow, et cetera, getting into systemic circulation. So, whoever. That's because you've done a, um, an operation that's pushed out into the circulation like reaming for intramedullary nailing, um, or if there's multiple fractures or conservative management and then inflammation causes damage to the bone marrow through that, And there's two suggestive theory is for the formation of fat emboli through either the mechanical theory or the biochemical theory, and it's probably a little bit too much to know about this for interviews. But essentially, the mechanical theory is where trauma whether that's the fracture itself or whether that's the reaming. When you operate on them, um causes the release of fatty tissue into the circulation through broken blood blood vessels, which then sort of propagate throughout the rest of the circulation. Or there's a biochemical theory, which causes inflammation. Uh, trauma rather causes inflammation, which then causes release of free fatty acids, and in reality it's probably a bit of both. But the end result is that it causes a classic triad of hypoxemia confusion and this particular rash as well. And they're usually really quite unwell. Uh, tachycardic tachypneic hypoxic. The main differential here is going to be pulmonary embolus. Uh, but this tends to happen, you know, a bit bit quicker and with an element of confusion and low grade pyrexia, which doesn't always occur with PE. And later there's evidence of organ dysfunction, too. Diagnosis is usually clinical, but there are these criteria which can help with your diagnosis. So there's major and minor criteria where major criteria is the classical triad of hypoxemia confusion and, um, that particular rash as well minor criteria are all more sort of non specific and more evidence of them just being unwell. So, um, you can look into good criteria if you like. It's a good little buzz word to get out for, um, an interview question potentially on this, although so it's probably quite rare. Management have said. Think of this like the pancreatitis of orthopedics because the management for this is largely supportive via, uh, respiratory support essentially so, actually usually required this. This guy will probably need to go to H. D. You free the high flow or intubation, and prevention can be an important mainstay of management to prevent how much bone marrow is this person into bloodstream? Bone marrow is quite quite fatty, so that, you know, can involve fixing long bone fractures as early as you can to avoid overwhelming the Medullary Canal. There have been a few studies about whether to use steroids for this. It's a little bit controversial as to whether to to use that probably best. Not to mention this in an interview question, because they'll probably just invite some questions that, to be honest, I I don't really know how to answer, um, prognosis. Mortality is 5 to 15% but you know, it's it's all very dependent on whether this is a co morbid patient with established respiratory disease. Who's got this or someone that's quite a bit more? Quite a bit more reserve about them. Okay. How are we doing for time, Sid? I have one more station that we could go through, which is a bit quicker than the others. Yeah, we're good. We're good for time. So the last station is, um, probably an old favorite as far as orthopedics is concerned. But whilst receiving your nightly handover, the wards your requested to review Mr See, a 19 year old patient who's still sore despite having some morphine. The nurse tells you, had some sort of surgery today for a fracture to his leg, but he's not going to settle. How are you going to proceed? And if you're wondering, it's the same answer as the last few. It's an 80 we approach using the crisp protocol. Thank you. Yeah, Good one. So here's the situation you've got, Mr See, he's 19. He's fit. And well, he had this football tackle two days ago and sustained this right midshaft hip hip fracture. We placed him into an above knee cast and he has had a tibial intramedullary nailing today. He got back to the war three hours ago. Uh, he's been on his or more of 10 mg hourly. He's taking his regular Kolkata mall as well, but he actually says that since he's had the operation, his pain is is getting worse and worse. His legs agony, um, beg you to do something about it because the, uh, pain is worse than the fracture was. So at this point, what could you do to help? Do you just look at his analogies here and give him a bit more and walk off? Yeah, exactly. So you take down his dressings. His cast removed the leg. Uh, so yeah, Exac. Exactly. Sometimes rather than being, you know what the ultimate diagnosis is. It's just a case of having too tight to cast and then just coming down. The cast allows the leg to have a little bit more freedom for for swelling post operatively, and sometimes that's all it needs. Elevating the leg is very helpful as well. Ideally, elevating the leg or the operative site above the level of the heart can help with swelling. Reduce that issue. Yeah, ice is a bit of a funny one. Um, I don't normally use ice for this, this sort of thing. Perhaps I should, um I I generally just take down the cast and elevate the leg. And then would you come back and re review this? If so, how How long will you take to come and have a look at this again? I come back in about 30 minutes, come back in about half an hour and and see if what you've done has helped with their pain at all. Um, it would be a good idea to check a few things around the leg now that you've taken down the cast. Um, it would be good to check what the neurovascular status is like. It would be good to see if you could feel any peripheral pulses, but it's also a good idea to see what the movements are like in the foot as well. And for that, we do something called passive stretch so passively and the toes, uh, and flex the toes down as well and see what the How the patient reacts to that. There might be some level of discomfort, but if there's, you know, pain, that's out of proportion to what you're doing to them. That's that's a very important finding. It's something that you should, you know, pick up on rather quickly. So you return 30 minutes later. Despite your best efforts, the patient reports being an utter agony. He's screaming down the ward for help and that know analogies area is helping whatsoever. So what signs on examination might you expect to find? So I just kind of mentioned it. Really? Pain on passive stretch decreased neuro vascular status. You? Yeah. Cold peripheries pain. Uh, um Mm. I I think if we've got a situation where we've got the five p's of acute limb ischemia, we probably missed the boat a little bit. Um, I would hope that at this point, you might expect you might find painful passage stretch subjectively. You might expect the compartments of the leg to be to be hard or to be stiff. Um, but I think if you if you're starting to get a pain, you know, painless, uh, perishing. Lee called Paris Thet Ick limb. That's yeah. Yeah. You probably miss the boat a little bit on this, uh, and and, you know, absent arterial pulse is is something you do not want to find in In in the what is the ultimate diagnosis here. But what is your differential diagnosis here? Because we've got a guy who's really, really saw there's paying out of proportion to the injury or rather the operation that we've done. Um, he's got a painful, passive stretch. And, um, you know, know analgesia is of any help. So the main differential diagnosis here you've said it. Raj is compartment syndrome. Other things might be a DVT or potentially an infection in the leg or even just, um, you know, somehow broken metal work or a broken screw. Or, you know, at this point, I think it's quite obviously compartment syndrome. So what must you do now? And you've actually already said it. Paddy, you You had said fasciotomy but escalate nil by mouth call senior ASAP. All very good answers. So, um, I would keep this patient fasted. Um, I would ensure that my senior, the anesthetic on call, and, uh, Seaboard coordinator was aware of this patient. I would consent them for a two incision for compartment fasciotomy. Um uh, as I say, keep the milk nil by mouth compartment Pressure monitors are quite interesting. Um, we don't tend to use them so much in the west of Scotland. But Edinburgh? Do I have used them for a few few patient's? And and then can you think of a particular scenario where you're You're wondering about compartment syndrome? But you are unsure if the patient is in a lot of pain? Because I've used compartment pressure monitoring for Patient's as sedated on ICU who aren't obviously going to tell you if they're sore because they're sedated. Um, which obviously is when, um, it's the only really scenario in which we would do that. Um, so when would you do bedside versus theater? Fasciotomy? Um, don't redo bedside fasciotomy is to be honest, uh, usually for something like that, that's a limb threatening, Um, issue. I would just generally just, uh, do a theater fasciotomy. Um, a bedside fasciotomy, I suppose, could be done. But I would obviously escalate your seniors before you do that. Um, e g. If there's absolutely no chance of getting any theater space, if this is something that's obviously deteriorating in front of your eyes, potentially if there's something that does have signs of acute limb ischemia. But that would be a, you know, a frighteningly rare thing and not sort of something that I would really recommend doing in your CST interview, um, about raising the leg as initial management. Is that therapeutic? More delirious if the patient has compartment syndrome delirious, Um, usually therapeutic because compartment syndrome is you to swelling within a closed my oh fascial compartment. So by it similarly to you know, your patient's with your ankle swellings preop. Elevating that above the level of the heart will reduce that swelling by, um, you know, reducing a dumb A and reducing inflow of fluid into that compartment. So it's it, I would have said It's therapeutic in the sense that it would slow swelling. Um, but by delirious, do you mean I'm not quite sure what what you mean by delirious? Um, All right, okay, anyway, but you're absolutely right. Call your seniors. Call anaesthetics. Call. See. Pod can send them for a fasciotomy. How many compartments are there in the lower leg? Well, there's four, um, the anterior compartment, the lateral compartment, and in the superficial and deep posterior compartments. And I don't want anyone to to waste their time on writing the definition for me. But compartment syndrome is essentially, um, a condition where there is, um, you know, unrestricted swelling in a closed myofascial or osteo fascial compartment. That then you know, has effects and increases pressure within that compartment, too. Then cause, um, effects with its own blood supply or nerve supply leading to subsequent ischemia and necrosis. So it's It's very much a very important thing to know about for your interviews, because it's it's something that means it's very time time restricted. Okay, so, yeah, this is me just with my answers again. So how are you? Hey, Andy. As per boast a two es per boast guidelines. So they're both guidelines for compartment syndrome are basically the gold standard for managing this. So if you have a look at the both guidelines for compartment syndrome, then that will tell you everything you need to know. Um, and it'll tell you the interval at which you need to go and reassess the patient exactly what to do on those reviews. Elevate the limb, and then these are sort of signs to be aware of. So, as I say, like pulses, late sign and you want to compare this with the non injured sign. But if this is someone who's got pulseless limb and someone who's got paralysis of that limb, that's, uh, injurious. Okay, my bad. Um, it's not more injurious if you do that for someone with compartment syndrome. Um, if they've got compartment syndrome, the injury will happen whether you like it or not. But slowing that rate of a Dema by reducing the dependency of the limb is going to be something that's gonna be helpful for them, or at least buy you some time. So I think you know, compartment syndrome, POSTOP hematoma, DVT and POSTOP pain all good differentials to come up with. So yep, perfect for those of you are struggling a little bit with thinking about consent forms or, uh, issues with, um, issues with consent forms. There's a good resource that's out there called Author Consent, which some of you may have heard of some of you may have used, but if you type author consent into Google and give you a sort of little man, and you can click on parts of the body and that will give you consent forms which are useful to read up on for sort of common trauma scenarios wouldn't be considered unsafe to wait 30 minutes at the start, as there is paying out of proportion already went. They need an urgent assessment after removing the cast. Yes, but you need to give time for your intervention. Are you cutting down the cast and elevating the limb to sort of take take place? So you know you can definitely quote the boast guidelines and say that this is sort of what you would do as per the boast guidelines. And that is what part of the guidelines are if they're absolutely screaming that place down and you cut down the cast and you find that there's a absolutely rock hard compartment and by all means, don't just go for a coffee for 30 minutes. Get get your senior in right away. But, uh, generally, as per the both guidelines, if you're suspicious of compartment syndrome, you'd want to do that first initial step and then wait 30 minutes to allow your elevation to help that a dumb a move out of the leg and, uh, and see if that provides any relief to the patient. But absolutely if they're going in with all the signs. As soon as you go and see them. Even after you cut down the cast, then you know, don't wait 30 minutes. Don't Don't wait on that at all. Um, but generally, it is a case of go do your initial intervention and assessment and then come back. But, you know, sometimes that's not real life, is it? Um, So four. Uh, yeah.