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Ok. Hello. Um We will just wait maybe a few more minutes for more people to 11 or two minutes for people to join in and then we'll make a start for those who are here. Welcome. Thank you for coming. Hopefully this will be useful. Sure. Ok. Yeah. Yeah. Yeah, one. So, all right. Um I think uh for those who are here, thank you for coming. I think we'll make a start and um people um other people can just join in. Um So first of all, just a quick introduction. My name is um Bell. I'm one of the core trainees, uh CT two in Northwest um working in Manchester Royal Infirmary at the moment. Um So today I'm going to take you through um the station. Well, I say station session, which is kind of that station. So we're gonna talk about communication and trauma management, which is part of our MRC S Dissected series. Um This will be the last two of our series if you've missed any of the previous one, they're all um recorded and on demand and on metal. So feel free to kind of go back whenever you want to look through and to listen through. Hopefully this is going to help. Um OK, we shall make a start. Um Right. So this is mainly um we talk about communication skills and trauma management principles um in the context of MRC S part B. So with um MRC S part B, um you will have four stations for Communication skills, two of which will be history taking and two of which will be giving and receiving information um one to patient or relative and the other one to a professional colleague. So that's what we'll go through as for trauma management. Now, strictly speaking, there is no um kind of trauma station in your part B exam. Um But there are three stations based around applied surgical science and critical care um which I think is where trauma management and ATL S principles can come in because they can t this to kind of a trauma scenario. And I think this is where we'll try and link it. So a session plan. So the first half of the session, we talk about communication skills, we'll go through an overview and we'll go through three example stations. The second half of the session will go through trauma management based on ATL S principles and we'll go to an example station. OK. So the first bit communication skill. So we'll talk about the history taking station, the one which you will have two of that in, in the exam So the basic outline, um there will be an examiner and there will be a layperson who will be the actor usually um unless they change it, but usually they'll get an actor to, to be the person that you take a history from rather than a real patient. So history taking basic stuff. So you want to um don't forget your basics. What I mean to say, you want to introduce yourself, you want to introduce your role, you want to check and confirm patient's identity and then you go on to take your history, which is what we all in thought in medical school, the basic kind of structure it still applies. So history of presenting complaint, any relevant systemic review, past medical, past surgical history, drug history, allergy, social history, all the lots that you know about. Um there may be bits that you want to focus a bit more on and bits that you go through a bit quicker. It all depends on the stem and what they want um what they're looking for. So it depends on a question. Now, from my previous experience with history taking, they may make the scenario a little bit more challenging. Um They may put in other concurrent issues that you would want to think about. So for example, there may be issue with patients capacity, safeguarding issue. It may be a really difficult patient that's not forthcoming in giving you information or issues to do with social circumstances. For example, so it may be a bit more challenging than kind of your final year of medical sy with these other issues that actually if you've been working as an F one or F two or in core training, you would have come across all of this. It's kind of something that you do day to day and usually with a history taking session, a station at the end of it, um you would want to have the management plan in your head because once you finish your history, you may get asked a few questions. OK. Moving on. So we'll go on to the first example for history taking. So you are act two on call for a general surgery at a district general hospital. You've been asked to see a 38 year old male in the emergency department who has presented with three day history of a right groin, uh right groin pain and swelling patient is a known IVD U. The are as shown and the question is um the instructions uh please take a history from the patient. So let's go back to this. So looking at this um in your head, you should have a few different shows in your mind, looking at the stem um for this, then you would want to think about groin abscess, groin cellulitis. Could it be a pseudoaneurysm and always think about things like necrotizing fasciitis because it is a uh a surgical emergency that will need to be um managed uh appropriately and in a timely manner. Now again, obviously, um the uh the patient is an actor. So wouldn't really have any pathology, but you have to think about some different shows in your head. OK. So how would you approach this? So, as we've mentioned earlier, the basics um introduction check identity gain consent. And then you want to go on to ask about the history of presenting complaint. So, um groin swelling, in this case, the onset duration, is it discharging? Is it pulsatile any other associated symptoms? Any systemic symptoms? Any, any kind of um relevant past medical or past surgical history? So, in particular, you want to ask about any previous similar experience, any previous surgical intervention, perhaps um any regular meds allergies, have they been started on some antibiotics in the community? Are they on any anticoagulation? So now this is um this will be relevant for surgery in general because that will affect your surgical planning. So don't forget to ask about that. Um And in this case, um any recreational drug use. So, in a stem, we've been told that this is an IV drug user. So you want to ask about um drug use. Are they injecting? When did they last inject it? Have they injected in your groin? Have they injected elsewhere? And then you want to cover the social circumstances? Smoking alcohol. Ok. Right. So in this case, um patient states that pain and swelling started three days ago in his right groin. It was not discharging, there was no bleeding, but it feels pulsatile. It feels like a moving lump. According to the patient, he last injected heroin into his right groin. Five days ago, he had some fever and feeling generally unwell previously, he's injected into his left groin and he's had a previous history of left groin abscess. And that was drained surgically and that happened about six months ago. And because of this, the patient said that, you know, I want some antibiotics for this and you know, just get it sorted, just drain it and get it sorted for me. Like before I know what this is right. Ok. So having heard that in your head, you want to think about, you know, what, what is your concern? So certainly this could be another groin abscess, but you do not want to miss a femoral pseudoaneurysm in an IVD U that has injected into the groin. So that is, so those two are the top different show that you definitely would want to mention. And once you've taken a history, um you want to think about um offering, well, obviously this is a history taking patient. You don't have to examine the patient, but if you have to examine at us. So what do you want to do next? You want to offer to examine a patient? Um You give your differential, you say that you are concerned a femoral pseudoaneurysm and uh versus a growing abscess. So you want to admit the patient, you want IV access blood and a CT angiogram. OK. So that is the main diagnostic um modality to rule out or rule in a femoral pseudoaneurysm. And it can also um let tell, tell you about whether or not there is an abscess or a collection. OK. So a CT angiogram is what you want. And if you are concerned about a femoral pseudoaneurysm or if the examiner then say Y CT shows a pseudoaneurysm, what do you want to do? Um So this needs to be referred on to vascular surgery um for this to be managed and this is an urgent, urgent clinical situation. And you want them if, if your local hos, if you're in the hospital that doesn't have vascular services, then you want to blue light them across to a vascular unit. Ok? And you want to um communicate this with the patient as well. So, um in summary, so with any history taking station, you want to have some different shows in mind and you want to have a management plan depending on what the diagnosis is. So if it is a growing abscess, then you know IV antibiotics, admit the patient um list them for uh an I and D an incision and drainage pseudoaneurysm. You want to refer to vascular surgery and um they may ask you then what do you think the vascular surgeon is going to do in this case. And in the case of um inject uh you know, uh pseudoaneurysm secondary to groin abscess or drug use injection, the uh management would almost certainly be femoral vessel ligation. Ok. So now we um so that is a history taking station part of the communication skill. And now we move on to talk about um the communication skills on giving and receiving information. So you will have two stations. Um One is a communication to a colleague, a professional colleague who will be the examiner and the other one is to a patient or a relative and you will have an examiner and an n so for this station, um it is a little bit different from all the other stations because you have a 10 minute preparation station. So you have a full 10 minutes of um well, in my memory sitting down in a room and um they'll give you a booklet or a or a file with all the information that you need. You will have time, well, 10 minutes and you, you, you're allowed to make notes and you're allowed to refer to your notes. Now, the information given um from my experience, it can be a bit overwhelming sometimes um because they'll give you um say a booklet of the patient details, age, um presenting complaint and it it might be in a format of like a war round type notes. So, on this day, um what round, what's happened? What are the investigation results? What's the plan, um, et cetera. So it, it, it can be uh a format like this. Now, you have 10 minutes to look through it, 10 minutes to make your notes. Um, jot down any salient points and there will then be an instruction. Um So let's look at a, a an example. So this is one giving and receiving information to a patient. So you are act one working with the general surgery team. You have been informed by a member of nursing staff that a patient under the care of your team wishes to self discharge. Patient is Mr Williams, 40 years old male who was admitted overnight following a road traffic accident where he sustained a grade two splenic laceration. He was admitted into the major trauma unit and his injuries were managed conservatively. The consultant on what round um what round plan from the general surgery team this morning was to continue conservative management with close monitoring. Please speak to the patient. Now, obviously, what I've given here is just a shortened version um without but, but you will be given much more um say blood results observation, day to day, kind of walk around plan. But um for the purpose of this session, um we'll just shorten it to, to, you know, give you a stamp and then um give you the instructions. So just an as an example. So with that stent um in your head it is a challenging scenario. You've got a patient with uh splenic laceration, a significant injury, but this patient wishes to self discharge. So you have to think about um Right. So I need to explain about the risk of self discharging. I need to explain about um what the medical advice is, what the recommendation is, which from the information that you've given is um to stay in hospital for close monitoring, at least for say a day or two. And apart from all of that, you want to think about does this patient has capacity? Because if the patient doesn't have capacity, then that changes things and that changes how you manage things. So in in this patient, you have to show that you thought about capacity and that you will assess capacity whilst you're giving um whilst you're chatting, talking to the patient essentially. Ok. So again, what you would do, so don't forget the basics, don't forget to get consent. Um In this case, you know, you can always offer a chaperone. Um and you can always ask if patient wishes for any next of kin to be present. So it is something that you know, you would do day to day. Um So think about this before even starting the conversation and this applies to other type of scenario, for example, breaking bad news. OK. So you can offer chaperone and you can ask if the patient um wish for the next of kin to be present. So for this station first, um obviously, uh you want to ask about how much the patient knows about the current situation um with the situation, I don't know. Um So there is this um spies model that you can use as a guide. So spies s for seeking information, p think about patient safety. I think about um taking an initiative to give the information e if you want to escalate and providing support. Ok. So for this specific um scenario, you ask about how much they know about the situation, you then proceed to explain about the situation. So explain about the splenic injury, needing close monitoring and then explain about the risk of leaving hospital. So risk of worsening of condition in this case, bleeding from the spleen which may require surgical intervention. So at the moment, it's conservative and monitoring. But if it starts bleeding or if the patient becomes unwell, this may require further investigation and intervention. So you want to explain this to the patient. And as I've mentioned earlier, you need to assess whether or not patient has capacity and that is whether they understand whether they can retain the information, um weigh up the pros and cons and that they need to be able to communicate back to you. Ok. So for this station, um your patient states that he understands all of it. But um he's worried about his elderly mum with cognitive impairment that's at home on her own over the weekend and he will need to get back home to make sure that she's ok. Um He states that, um, you know, he understands what you're saying, he understands the risks. He is aware, but he would still like to self discharge and he's happy to sign any paperwork that is required. So now that um, so if you've decided that, you know, the patient has capacity, so you need to respect patients autonomy, you can't force them to stay in hospital and um you need to respect their wishes. Ok? So what you need to do so given that you've established that patient has capacity and still wishes to self discharge, they should be respected. But you need to demonstrate that um you will try to manage this issue as safely as possible. So what you can do is you can ask for um an an updated set of observation before the patient leave the hospital to make sure that they are stable. You want to give them safety netting advice and you can offer them written information or any patient information leaflet. So these are the things that you can offer to make this situation as safe as possible. Ok. You can offer things like, right? This is the number of the trauma ward. If you've got any worries, any concern, give us a ring. So things like that. Ok. Ok. So that was the um station on communication to patients generally it's not, it's not too difficult, um not too difficult to navigate. Um It is something that with a bit of practice and um you'll be able to um to, to smash it. Now, let's talk about um the second bit uh which is giving and receiving information to a professional colleague. So this example, you are Act Two working at a tertiary vascular unit. You have been asked um informed by a consultant that the on call team has listed a patient for an aorto bifemoral bypass on the emergency list today. And the patient will require an ICU bed, postoperatively. Patient has bilateral critical limb threatening ischemia due to complete infrarenal aortic occlusion. Please discuss with the ICU consultant on call. So again, um unless they've changed it in my experience again, you will be given a booklet with a fair amount of information relating to the patient's admission, progress, diagnosis, scan results, blood results, et cetera, et cetera. Take the time to write the notes. You can refer to this and when you're talking to a professional colleague, a handy um format that you can always refer back on as everyone would probably know about is the sbar format. So situation background, your assessment and recommendation. So it's a good one to kind of um go by when communicating with a colleague. OK. So how do we approach this? So basics introduction. So hi, my name is so and so I am the CT two with the vascular team. Um I gather that you're one of the uh ICU consultant on call. Um Thank you for talking to me. Um I would like to talk to you about a patient um that requires an ICU bed POSTOP and this patient has been listed for uh an urgent aortobifemoral operation. So, so something like that. OK. So the main thing to say is you want to then summarize the key clinical problem in this case, critical limb threatening ischemia. Any relevant uh recent investigation results. What is the management plan in this case? Um This patient needs urgent revascular revascularization uh in the form of an ABG and they it it is a major operation and they need an ICU bed POSTOP. Now with this station again, you may be thrown with some difficulty. So the ICU consultant may challenge why an ICU bed is required. They might say, look, the patient has a fairly good baseline. Um Why do they, why do they need an ICU bed? Or they may say look, there's no bed available currently, it's all full or there's only one bed available. And I've got a young unwell patient with brittle asthma in rhesus um at the moment and that patient is going to need an ICU bed as well. So when this happened, just keep calm, keep professional, never argue with a consultant, never argue with a professional colleague. Ok. So you want to explain that you know this is a major abdominal major aortic surgery. Um If there are any comorbidities, you want to explain that and explain that, you know, this is what um what your consultant have asked you to do as well. But don't just say that. Um, also explain, as I've said, major abdominal major aortic surgery, um will require HD U or ICU input after the operation. Now, you can also um try and explore other options. So for example, you know, if, if you've been told that, you know, there's no beds, it's chop block, it's awful. Um You can potentially offer to rediscuss with your own consultant about whether or not, you know, if we've not going to ICU bed, would a hu bet be appropriate. Could this be an option or, you know, things like could this operation be delayed maybe to tomorrow or this evening or until we get an ICU bed? So these are the things that you can try and offer um because that shows that you are um actively looking for a solution and that you are resourceful and um you are kind of thinking laterally of what are my other options? OK. I hope that makes sense. Um So basically, in summary, for the station, uh for the communication skills station to patients, um you want to show empathy, understanding and respect, um you want to listen to the patient. So don't forget to listen, don't just talk to them or talk at them but let them talk. Um explore their concerns. OK. Those are the main things um for communication to a colleague, you want to be polite, always be polite and be professional, be concise in your summary and your referral, be concise in what you want. Uh the outcome that you are aiming for. OK. So be clear about it and be clear about the rationale of why you are aiming for that outcome. OK. And then just have a conversation. All right. Ok. I think, um, well, I think if you've got any question, you can always pop on a chat box. So if I'm not mistaken. Yep, that is the end of the first half of the session. I think the timing is not too bad. Um, I think we're doing quite well with time. Um, so those are the, um, the bits on communication the next half, uh, of the session will be about trauma management. So if you've got any questions, pop me in the chat box. Um, otherwise I think we will crack on with trauma management a little bit different, it feels like going from one different thing to a completely different thing. But, um, let's hope this, uh, will be helpful to you. Ok. So for those of you who have, um, managed to attend the ATL S course, well done, um, it is a really good course and frankly speaking, um, I, it is a bit, um, difficult to sign on, um, you know, according to lots of feedback from people, it can be a bit difficult to, to sign on to it. So if you have the opportunity to get on it, um plan early, look at when they're running the course and just, you know, put in, put it in your calendar and sign up early. It is a really, really good course. So I will go through um trauma management based on ATL S principles. Um So that in general is summarized in this slide. So the first thing is primary survey and then you can take a focus history um in brackets and then you think about do we need to transfer the patient and then secondary survey, we evaluate and definitive care. So these are the main bits um for ATL S which is the advanced trauma life support course for those of you who don't know. Okie Dokie. So first bit primary survey, it's just like your ABC. OK, with a bit of modification. It is also a two E OK. And we talk about the um other little bit that is specific to trauma that you want to think about. So, airway um in ATL S airway, when you, when you think about a airway, you want to think about C spine. So airway and C spine always comes together. That is your first bit. And then B breathing and ventilation, C circulation and hemorrhage control. Ok. Trauma bleeding comes together, think about it b very much the same neurology and E exposure and environmental control very much the same. But um in trauma, um you want to, there are a few things that you want to think about. We go through it. So ABCD E and you do it just like your A LS in, in um in sequence. So always start with a, always move to B only when you're happy with A OK. So A to E but um in practice, um if you've ever been to a trauma co or if ever worked in a trauma center, these steps are usually performed simultaneously at the same time because you would have someone doing an airway. Um someone assessing the breathing, someone putting in Cannulas. So it usually will happen simultaneously. Ok. So let's go through them. So first bit airway and C spine, sorry about the very busy slide. But um there is uh a fair bit to talk about in your airway and C spine. So airway check airway. So again, similarly to a LS or you know, your A to E assessment of um any unwell patient, you want to say hello to the patient? So say hi. Um talk to the patient and if you get a response back, an appropriate response, say oh yeah, hi. My name is Tom. It's really sore. Can you help me out here? You know, that gives you a clue that um there is one, no major immediate airway compromise because the patient is talking to you breathing is not severely compromised. And if they're making sense, then the level of consciousness is not markedly decreased. So, in, in this first few seconds of talking to the patient, you get valuable information. Now, if you ever been to, if, if you've lucky enough to, um, attend an A T LFs course you will be told about, um, and repeat it upon what is called the ATL S handshake. So when you check airway, you would restrict c spine at the same time. So what you would do is you would go to the patient, say hi to them, talk to them. And at the same time, you restrict the C spine with your hands, ok? With both your arms. So that is the ATL S handshake and that is what you do at the start of every ATL S scenario and well in real life as well. Ok. So airway NC spine. So once you've done that, then you want to check the airway for any signs of obstruction. So any obvious foreign body that you can see any mandibular or facial fractures that may impact on the airway, any blood or any vomits that you can suction. And then again, the basic stuff of um basic airway maneuvers, you've got your jaw thrust or head tilt, chin lift, but be careful in trauma. You don't want to do a head tilt, chin lift um in a suspected C spine injury. So I normally would just go with jaw thrust. Um And then you can think about airway adjuncts if you need them. So the nasopharyngeal airway again, be cautious because it is contraindicated in basal skull fracture, sorry about the typo. Um Or uh the next thing that you can use apart from an NPA is an O PA to an oropharyngeal A gels airway. Um So another note to remember if you put in a gel and if the patient is tolerating that. Absolutely. Well, then this is a patient who is likely to require an intubation. Ok. Um Other things um are supraglottic airway, like your um laryngo mask airway or an eye gel. And, and then you move on to definitive airway such as E tt endotracheal intubation or um a surgical airway, which is your cricothyroidotomy. So if you attend the ATL S course, they'll teach you how to do all of that. Well, we're not gonna go through all of that today. Ok. Now, the other bit about airway that you want to think about is um if the G CS is eight or less, then they would require prompt intubation. Um and with your c spine, so you can't do the ATL S handshake forever. You can't just put your arm there forever to restrict the C spine. So you want to then have your three way immobilization with blocks, tape and collar. So that is airway moving on. You want to assess breathing and ventilation. So um stick them on a high flow oxygen via a 15 L non rebreather. And then you want to assess um well, obviously, you want to get uh what is your respiratory rate and what's your saturations and then a visual inspection of the chest wall? So, is there any bruising, is there an open wound? Is there any evidence of ala chest you then palpate for any tracheal deviation, chest wall movement, percuss any hyper resonance that you're worried about or it is dull and you want to listen for uh entry. So, in particular, in a trauma situation, you want to look for tension, pneumothorax, which will require an immediate decompression and chest string, open pneumothorax, which you would treat it with a three way tape and then a chest drain, massive hex, a chest drain. And um if you put in a chest drain and more than a hu a 100 and 1000 or 500 males, then that requires urgent thoracotomy or urgent cardiothoracic consult and look for the flail chest. Any evidence of fla chest and the adjuncts for your b breathing or ventilation is you can get an urgent portable chest X ray moving on to see again, apologies for the um busy, slight, but again, with trauma, this is uh a fair amount to talk about. So, with circulation and hemorrhage control. Um first of all, um you want to, you, you would want to have your um observation. So what's the heart rate? What's the BP, any obvious bleeding. So with trauma, there are five bits of the body that the patient can bleed a lot into. And that is your chest, abdomen, pelvis, long bones and well, strictly speaking, floor is not part of the body, but it just means that you want to look on the floor to see if there is any large amount of bleeding. And if so you want to look, look, you know, look for where it's coming from and stop the bleeding. So chest abdo Pelvis, long bones and floor, OK? With any obvious bleeding, if anything that's bursting in front of you, first thing you would do is to put manual pressure on it. If that doesn't work, then consider a Tonique. If you put a Tonique or if a Tonique is applied on a patient on a limb, then the time of application needs to be noted because you can't put a Tonique on for um for hours, OK? That um has a risk of limb ischemia. So Tonique on record the time and then think about giving Tranexamic acid. So IBS um is necessary. Um but in trauma, think about um alternative, which could be a human IO So that's intraosseous access. Um in the atl s course, they will teach you how to do it, but we're not gonna go through it here. Um So access, intravenous or intraosseous. If you cannot get an IV access, you want to send off bloods for cross match and you want to activate a major the major hemorrhage protocol, uh, as per your hospital guidance, if there is, uh, if you're concerned about major hemorrhage, and as we've mentioned, assess the heart rate, BP, assess the skin perfusion and then assess the heart sounds. Um, mainly to look for any evidence of cardiac Tampa that you want to deal with because that is a life threatening injury. Um, and the uh commonly the, the backs triad, what we call the backs triad are um a triad of hypotension, muffle, muffled heart sounds and this tendon neck veins. Um If you're suspecting cardiotin art, um you can do an urgent um bedside echo or an ultrasound scan to look for it. Now, um it may seem a bit um different um in atl s uh trauma in the sense that within C within your C for circulation, you want to examine the abdomen and the pelvis. Usually, um you know, with your A LS or normal A two E assessment, your abd pelvis may come under e in exposure. But in trauma, you always um put um abdomen and pelvis in C because those are the two compartments, the two bits of the body that you, that patient can bleed a lot into. So after you've assessed the peripheries, um heart sounds, you want to examine the abdomen and pelvis. So any abdominal wound are they peritoneal, which may make you suspect of intraabdominal bleeding. And if you're suspecting any pelvic injury, you want to put on a pelvic binder. The other thing about um C uh in ATL S is the um shock and trauma. Once you've ruled out tension pneumothorax or cardiac tampon, it's presumed to be secondary to blood loss until proven otherwise. Ok. So that is the mantra of ATL S. So other causes of shock, for example, can be spinal shock, but you always want to um rule out uh bleeding, hypovolemia secondary to bleeding, ok. The adjunct for your circulation and control your C bit would be you can get an E CGF scan and a pelvic X ray. Now, um before moving on to D um uh there is this pneumonic um at FC. So you want to make sure that you've excluded these life threatening injuries such as any airway issues, tension, pneumothorax, open pneumothorax, massive pneumothorax, flow, chest, cardiac anti, that you want to make sure you've exclude all of that, that you're happy that you know, you're not concerned about any of these. Ok? Ok. Now, the neurological, so um similar to normal A to e you want to check and document G CS, um you want to check for pupillary reflex, you want to also examine for any external evidence of head injury, um or signs of basal skull fractures, any neurological deficit and you want to check blood glucose. So, as simple as that s for e for exposure, you want to make sure that you've got adequate exposure whilst maintaining warm. Ok. So check the patient's temperature and you want to examine for any other obvious injuries that needs to be addressed ASAP in your primary survey. So for example, a deformed limb that may need to be splinted or any open wound or laceration that's bleeding that needs to be addressed. Ok. So you want to look for those things, right? So that is um in a nutshell, your primary survey at the end of your primary survey, the question you want to ask yourself is is this patient stable? So if the patient, if you manage to stabilize the patient and you know, the patient's not unconscious or unstable, you want to try and get a focused history. Um A good pneumonic that is commonly used in the trauma situation is ample. So you want to ask about allergies, medication, any past illnesses in a women in child with uh in childbearing age, you want to ask about pregnancy. Well, not just ask, you want to test the pregnancy status. Um When did they last had something to eat and drink last meal? And what are the events leading to the injury? So quick focus history. And if the patient is stable in most trauma center, um they will get, they usually get a trauma ct. So that's a pen CT CT head, um chest abdo pelvis. And if you go up, if, if you attend the ATL S course, there is always the thought about do I need to transfer the patient? Because you need to take into account of whether or not your unit has what the patient require. So for example, if you're suspecting a um intracranial injury, um or if a CT head shows that you know, there is an intracranial bleed with midline shift and they need neurosurgical opinion. Then the question is whether or not your hospital has neurosurgery because um not all hospital will have that um with centralization of services. So you want to think about whether or not you need to transfer the patient to a hospital that has the service that the patient require. I hope that makes sense after your primary survey. Then you can um think about doing a secondary survey. So that's only after you've completed your primary survey and that you're happy that the patient is stable. So secondary survey, what does that mean? It basically means a top to toe examination to look for any other injuries that you may have missed during your primary survey. Um You may want to um not roll the patient to examine their spine. So ac spine, thoracic lumbar spine, pr examination. So you may want to do that in, you can do that in your secondary survey. You may want to get some peripheral x-rays depending on your findings. So for example, they may have uh you may find a deformed wrist and maybe a distal radius fracture that you want the peripheral x-rays for. Um once you've done a top to toe examination, then you think about um definitive care. Like what does this patient need? Ok. But again, this is after you're happy that you know, they're stable from the primary survey, sometimes um secondary surveys sometimes happens after definitive care for primary after the primary survey. So for example, if um in your primary survey, you, you know, they need to go to theater, so they go to theater, they come back from theater and sometimes secondary survey happens when they are on the ward, for example. Ok. So it's only after you've sort out any life threatening injury that you need to treat. Ok. Let's go on to an example. Um I realize we've been talking for a little while now, but I promise this is the last example. Um So patient is a 45 years old brought into the ed after sustaining a road traffic accident, he was driving a motorcycle collided with a car whilst entering around about at 40 miles per hour. He was off his motorcycle and landed on the road. The emergency services was called and attended within 15 minutes. Patient was brought to your major trauma unit. Um It's just to say that the driver of the other car managed to stop safely and did not sustain any injuries just in case you're wondering. So upon arrival, excuse me, observations are as given. So pulse rate 100 and 20 BP, 90/65 respiratory rate, 25 set, 96 and temperature 37 2. How would you assess the patient? So our A to E so atl S handshake airway and C spine is the patient talking, is he conscious c spine immobilization. And then once you're happy with A and only when you're happy, move on to B so apply high flow oxygen. Examine your chest, rule out any tension, pneumothorax, any hemothorax, um get a portable chest X ray. Do they need a chest drain? Once you're happy with that, move on to see um heart rate, BP as given. So they're tachycardic hypotensive. You want to make sure you've got IV access, you want to send off bloods, um you want to send off a quick blood gas that can give you a quick idea of what the HB is. But always remember in trauma, in acute bleeding situation, they may not have a HB drop. Ok. So a normal HB doesn't mean they're not bleeding. Um And then think about whether or not you need to activate your major hemorrhage protocol, fluid resuscitation and blood res blood product resuscitation as well if you think they're bleeding. And then um think about again, the five bits that they can bleed from the chest, which you should have assessed in your B abdomen, pelvis, long bone floor happy with C moving on to D any disability G CS, pupillary reflex, blood glucose, any evidence of head injury, any neurology, are they moving all four limbs and then move on to exposure to look for any other um injuries. So in this case, airways patent c spine is immobilized. Um there is no immediate life threating breathing issues. So you're happy with the SS, you're happy with um the chest, happy with breathing. Um So on arrival, they were hyper, sorry, hypotensive and tachycardic. So a bolus of warm IV fluids were given. And after the fluids you see some improvement, the heart rate is now 100 BP is 100/70. When you examine the abdomen, it is tender over the left upper quadrant, the pelvis are fine and then moving on to the um so at this point, um with the C you have somewhat stabilized, you know, the heart rate, BP has improved, but the abdomen is tender. So you want to think about any intraabdominal bleeding and then you assess your D. So G CS 15 BMS are normal. Pupils are fine. There's no obvious head injury and the paramedics um helpful brought in the helmet as well and said that, you know, it's in good condition, it's not damaged. Um um when you assess um e appropriately expose a patient maintaining a warmth, um you note an obvious deformity to the left lower leg with an open wound. So to summarize what are the issues? So A and B satisfactory. Happy C Well, you're concerned about an intraabdominal injury, possibly bleeding. D quite happy. E you're worried about a left tip FP open fracture. So you've got your, you've got your issues here. So you what you need to do. So once you've stabilized the patient, you want to try and get them a trauma CT because that's gonna give you your answer. But whilst you're by the bedside, you can also um perform a fast scan. So a bedside ultrasound scan to look for any free fluid, any free fluid in the abdomen. With this picture suggests intraabdominal bleeding, needing um surgical exploration. Um So that is your c bit. But then remember you've also identified a left tip that open fracture. So for any open fracture, um the initial management, according to the both guidelines, you want to remove any gross contamination, you want to take some medical photos so that you don't have to um open up the wound again, take some medical photos, dress the wound with saline soap gauze, cover the wound, splint, it put a backflip on. Ok. So that's the um basic initial management for open fracture and not forgetting things like tetanus and IV antibiotics, right? We're coming to an end. So that is an example of um trauma management and it could be something that can come out in the um in your critical care station in your MRC S. So once you've run through the station and said this is what I'm gonna do A to E blah, blah, blah. At the end of it, some questions that you may get us. So classes of hemorrhagic shock, what's the initial management of open fracture? What are the differentials for intraabdominal injury? So it could be liver laceration, a splenic la a splenic laceration, bowel injury. And that could carry on to what's the management for spleen laceration and what's the post splenectomy management? So these are the potentially the questions that you may get asked on? Ok. Right. So now we're getting to the end. Um in summary, we've gone through um in this hour, um hopefully not too draggy. Um The first half com on communication on the history taking and on communication, colleague and patient and exam stations that may come up in your exam. And we've gone through principles of trauma management based on ATL S principles and all of this is um based on MRC S style questions um similar to um MRC S exam. OK. So that was my experience anyways having done the exam. So that is the end of it. Um This is my email address. If you've got any further questions, feel free to drop me an email, any questions at all, there is no silly questions, feel free to ask anything. Um Yeah, and I'm happy to answer them. If you've got any questions in the chat, I will stay on for the next kind of three minutes that will take us to eight o'clock. Um, if anybody has any questions. Thanks for coming.