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So for those of you who haven't joined us, we'll just go through how the stations are run and then we'll run through a much case and then we'll just have a General Q and A at the end for you guys to ask any general Os questions that you have. Um for the disclaimer up, uh We've designed this um to basically help find out your students with practical ay skills. Uh It's not a replacement for university teaching and it's not actual medical advice. Um It's based on the last Ross, but it's applicable to the finals, OS and most universities. And we do pay, review all the content, but we take no responsibility for the accuracy. So if you do have uh any concerns as to the content or notes, any errors just drop in. Now, we'll correct it and then all the, all the sessions are recorded, it'll be, it'll be published on me. Uh If you come to the session and fill in the feedback, you'll get instant access. Um But if you aren't able to fill out the feedback, it'll be made open access towards the end of January. Once the program is completed there are a team of doctors who are putting all of this together. Um, and you've probably seen quite a few of them already and you'll, you'll meet the rest as the, as the course goes on. So I'll hand over to doctor, go to take you through the first station. Hi, everyone. Thank you very much for the introductions. Um, so for those of you who don't, who don't know me, my name is Nia. I'm one of the doctors uh working in the northwest scenery and I decided to create this course um along with s to help you guys with your finals. Ay, so today is our last session before Christmas where we'll go through a few stations. So I'll go through specialties within the ed with you guys. So this is a station which will be running over 10 minutes. And as any other case, you have two minutes to read through the instructions and also brainstorm your ideas. So the instructions the university has given is that it could be a station from any specialty uh with an emergency presentation. So these are your year for rotations. And um it's a very broad station. You will be asked to take a history and this could be a history from the patient or the accompanying family member if it's a child. Um You could be asked to do a physical examination or the station could just be a talking station where they're actually willing to assess higher level communication skills and you could have real patients or you could have models and, uh, this could be a mannequin to represent a child. And if you have real patients, it's more than likely you're going to be asked to examine them as well. Um, so with cessation, you are expected to diagnose and also indicate what appropriate investigations you're going to do and also come to a reasoned management plan. And all of this, as I say is fairly broad and this reflects in the mock scheme as well. So they're uh looking to see that you are skilled and fluent with your you're taking and you're covering as much of the ground as possible and you're confident in your approach to the patient diagnosing and also explaining what's going on with the patient to them. And also coming up with a management plan they can understand without any jargon. So it's fairly broad and a lot of these things will be tailored as per gestation you are having in your actual ay. Um So with this station, then it's very reasonable to revise pretty much a little bit of everything that covers the case. So go through your anatomy, go through your pathophysiology, uh go through the signs and symptoms, you'll have what are the differentiating features and also then cover the management plan. And this is again, very broad to cover your medical surgical, uh but also lifestyle management as well as looking into perhaps any charity or the social support available for the patient as well. So keep those things in the back of your mind as you are brainstorming, what to do with the station in the two minutes you have prior to starting to talk. So just a few tips, um the station is designed so the examiners can evaluate your diagnostic and reasoning skills and they're wanting to see how well you can come up with a plan in the 10 minutes you have for the station. Um So what my recommendation is focus on your differentials early on. Um So group them into most likely diagnosis, diagnosis not to be missed. And also remember for your red flags and screen for any risk factors when you're taking a history because that is more than likely to help you guide towards a very appropriate differential for this case. Um And also as I said, revise your emergency presentation from OBS and G pediatric psychiatry, ophthalmology, neuro ent dermatology and oncology. These are the main stations you are likely to get in your oy and then also keep an ear out for safety concerns, as I say, um is there any safeguarding uh related to the presentation or when they are being treated? Do you need to put in mind any safeguarding concerns, either for the patient or people who are at home from uh the patient's uh living situation and also driving? Are they safe to drive and those kinds of things that you'd cover for other stations anyway. So here's just a list of potential cases that can come up, feel free to take a screenshot of this. But also definitely go back to your curriculum from year four. have a read through what is most likely to come up and also discuss with your friends the kinds of, um, investigations you would do for these, the management plan you would have. And as I said earlier, um look into medical surgical as well as lifestyle management for all of these cases. Then um again, screened for conditions through the surgical si found that was really good, especially if I'm not quite sure what could be going on if somebody comes in with nonspecific abdominal pain. Um I will go through this uh pneumonic called Vitamin C, which you guys can all Google if you don't know it already. So go through this to work out what could be going on with the patient and what management you need to do and how quickly you need to implement it as well. So again, some differentiating features to ask in your history is what is the symptom? Firstly, what is the onset, uh whether it was acute or chronic or acute and chronic presentations. So sometimes patients with CKD can have AKI which is an acute complication. So keep that in your mind. Um ask if there are any patterns. So say the patient is vomiting, they're bleeding or they have, which comes in a specific pattern that can give you more of a direction as to what the diagnosis is. Um look out for any triggers. Um Also, do they have a fever cause if they have a fever, you're thinking more of the inflammatory and infectious conditions. Uh Do they have any associated dizziness, which can be an indicator that the brain is involved or they're having hemodynamic compromise. Then again, our, are they vomiting? Are they eating and drinking? This just gives you an idea about their um physical status and the time being and guide you whether you need to admit the patient or not, especially for pediatrics because if they have a respiratory condition and they're not eating or drinking more than likely they'll need to stay in the hospital. Otherwise, mostly you can give them a management to carry on at home and safety net them as well. So um seeing as how this station is very broad, I thought instead of running through one example, I'll go through a few different examples and I'll give you guys two minutes each in your own time. Um Brainstorm, what you think could be the differentials and how you go about managing it. And for each differential, just think what is the medical, surgical and lifestyle management. So as a first case, um you guys can grab a pen and paper, I'll give you a few extra seconds for that and I'll also get my timer up. So, uh for the first case, imagine you are the fy one in the emergency department. And Audrey Edwards is a 78 year old woman who's presenting to the ed with vision loss. And you have 10 minutes then to take a history from the patient, explain the likely diagnosis, any investigations that may be required for this presentation and your management plan and all of this discussion is happening with the patient And then also towards the end, answer any questions the patient has as well. So I'll give you all two minutes to brainstorm your ideas and then we'll go through an example approach. So two minutes starting now. Ok. So how is everyone getting along? Are you happy to go through the, um, approach or do you need some more time? Just pop in the chat, happy to go through it? Ok, fantastic. So these were a few things I thought of when I would want to, uh, take a history from this patient. So firstly, I would want to ask about the onset. So, you know, how quickly did the loss of vision come on? Um, and also I'd want to clarify whether she anyway has problems with her vision and if this is something that's worsened, um, or if it's something that's just suddenly come on, she's never had any problems with her vision, no glasses at all. So clarify the baseline and then ask about the onset as well and then the second thing you want to ask is was there pain? Because in ophthalmology, one of the big red flag conditions are painless loss of vision. And if the patient does have pain, you're thinking along the more um like glaucoma or other side of things where there's an infection that's actually causing there to be troubled with the vision. Um But if it's painless loss of vision, we're thinking more along the conditions where there's a blockage of blood supply or there is detachment of the retina, then also ask about visual acuity. As I said, um ask about any discharge. If there is any um any associated symptoms, are they having a fever, are they vomiting cause these kinds of questions can all give you an idea of how much systemic upset there is. Um And then ask about their past medical history and risk factors. So parti particularly with ophthalmology, we want to ask if they have any diabetic history, hypertensive history. Um And also sometimes family history can be a good idea to ask as well if you have a condition in mind that you want to just rule out as well. Um Ask about things like, do they have any muscle pain? Do they ever struggle with weakness? Do they have any jaw claudication? Because we want to also keep an eye out for GCA. Um So as I said, these are some of the differentials I would have come up with for the station without even entering the station without talking to the patient, I would want to rule out these things. So GCA central retinal artery occlusion, vein occlusion, detachment of the retina or the vitreous, but also vitreous hemorrhage, and also a stroke because you do not want to miss a stroke, especially ones that are more um blister with not such very obvious symptoms. So always just screen out for these things and then the kinds of investigations you'd want to do again as always break it down into bedside bloods and imaging. Um And with this one, you'd want to do an ophthalmologist, ophthalmological examination where you look at the eye with a fundoscope and then also a slit lamp examination, check for visual acuity, visual fields, all of that you'd want to do and then also just, just do an ECG as well because in case the patient has af it could have led to them having either a stroke or it could have led to them having um an occlusion in their artery in the eye. Then bloods, you'd want to do the routine bloods, like doing urine electrolytes, full blood count. Um but also do coagulation check for hemo uh check for HBA1C and also do their lipids in the blood test as well. Um The other thing you'd want to consider doing is a temporal artery biopsy or an ultrasound and this is more related to GCA. So all of these investigations, I'm telling you are just some things you'd want to keep in the back of your mind. All of these are not always relevant. It will just depend on what the presentation is. And then when it comes to management again, medical, does this patient need aspirin? Does this patient need steroids? Um surgical? That's there's lots of different things but know what surgical management options are out there for retinal detachment and for glaucoma as well cause they are tend to, they tend to be the more common ones that the examiners will ask you about. So things like um pneumatic retinopexy or if you are um uh sending the patient over for vitrectomy as well. So these things just keep some idea about it and ask if they won't ask you too much detail, but just know a little bit about it. And then also with lifestyle um is the patient safe to drive um will charities be able to support them with anything else after they have had this diagnosis? And in the meantime, when they are dealing with this vision loss? Um And then the third thing is, do you need to consider registering the patient as blind, depending on how uh bad the loss of vision is. So that's the case one, any questions about that at all before we move on? OK. If there are any questions, just pop them in the chart, but we'll do a similar thing where we'll go through case two. And again, I'll give you guys two minutes to brainstorm your ideas. So in case two, then you're in the emergency department again, working as the fy one. Now you have a 32 year old Primi Gravida who's presenting with PV, bleeding at 34 weeks gestation, and you'll have 10 minutes then to take a history from the patient, um explain the likely diagnosis and investigations that may be required and also what your management plan is with this station. The examiner might as well ask you to do an examination. So they could say, uh you will need to examine for the lie of the baby where the head position is and also auscultate using a Pinard as well. So it could be either way just make sure you know, your obstetric exam for this kind of gestation as well and then also answering questions the patient has towards the end of this station in our case. So I'll stop the two-minute timer. Ok. So that is two minutes. Let's just go through the approach I would take for the patient. So some of the things I would want to clarify in the history again, is the onset of symptoms, the pattern of the bleeding if there is any pain associated as well. And if there is bleeding, how much has she bled? Um has she had any other instances earlier in the pregnancy of bleeding as well? The other thing to clarify is did she have any discharge? Um And if she did, what kind was it? Um, often at this kind of a gestation, you want to also keep an eye out for bursting the water. So ask, was there any incident like that in the last few hours or days as well? Um In terms of associated symptoms, again, ask about fever or any other things like vomiting, then having any dysuria, these things you just want to cover as well in your history. Um And then if you were to examine the patient, one thing you want to keep um an eye out for is tenderness of the uterus. Does it feel hard and woody? Because if that is, it would indicate the patient could be having a placental abruption. Um, placenta previa is one other good differential to have. And if the patient did have symptoms that are indicating discharge or breaking the waters, you're thinking that the patient actually rupture her membranes and is it preterm depending on how many weeks the patient is? So some investigations to consider involve looking after both the mother and the baby. So make sure the baby is all right by firstly, just intermittently auscultating or putting the patient on a CTG uh to monitor the baby's heart rate and any uterine contractions as well. Then again, take your bloods including hemoglobin clotting group and save um clear how if the mother is known to have a negative uh blood group. So if it's A minus B minus all of that. Um do an ultrasound as well to look for concealed bleeding. Um but also to make sure the baby is all right. And whether the gestation matches these kinds of things are case by case. So just um do it as for what's presented to you in the history and then you might want to consider doing swabs for the patient. So there are two things we have swabs for an obs and gynae. One is to check for preterm labor and the other is to check for rupture of membranes. So, fetal fibronectin swabs are to check for pre uh uh for preterm labor. And then the P MG one and the if F GBP one, basically, these are the NIS sure and actin prom tests. These ones are to check that the patient hasn't burst her waters already. So have a bit of a read because these are very important to know that there is a difference between the two kinds of swabs you do for patients. Um And then in terms of management, again, medical versus surgical and also lifestyle that you want to consider in the longer term. So when I say medical, what I mean is if the patient has a negative blood group, do you need to give the patient steroids? Um If the patient is um what was I saying? Yeah. So any steroids and then also if the patient is in pain, make sure you give them painkillers. So these kinds of basic things you want to sort out. And then in terms of surgical as well, does the patient need to be induced or does the patient need to go to theater? So this will depend on a case by case basis. And then in terms of lifestyle, uh um smoking is a very big risk factor for placental abruption. So you want to just counsel the patient on this pregnancy as well as the next one. So they're aware that this is a risk going forward as well. And then also with placental abruption, one of the factors you do want to rule out is was there any trauma that led to this? So this could be anything like the patient getting involved in an unintentional accident or it could be domestic abuse. So these kinds of things, you just want to make sure you screen for as well and often there are a few small cues the actor will give you as well. Um And that would then prompt you to talk about safeguarding. Um and also in, in forming anybody else who's relevant um like any other family members, there are any other Children there are and especially if a mother has come into the hospital and you know, she's going to be admitted. You want to just make sure are there any other Children at home and if they are, is there anybody who can look after them and the school need to be told for them as well that um, they're, they're not able to come in. So these kinds of things you just want to have in the back of your mind with a case like this. Then case three, let's proceed. We have total four cases. So with this one, you are again the fy one in the emergency department. And Jasmine Brown is a 13 year old who's presenting to the ed with Susan, who's their mother. And they want you to take a history from the mother for abdominal pain. So somebody like before, think about the diagnosis, investigations and your management plan as well and answer any questions the mother has this time. So two minutes starting now. Ok. Everybody. So that is two minutes. Uh Let's go through an example approach. So yeah, firstly, I just wanted to remind everybody again, revise through your abdominal lesions. Again, the kinds of pain that could indicate different conditions. Um And in someone who's a 13 year old girl that could be also gyne conditions involved as well. So as with any other pain, you do a squitter history as for the site of the pain, the quality, the in intensity, the triggers, um any aggravating or relieving features and um or what time period this happened and any associated symptoms. So particularly you also want to clarify the pattern. So does the pain come on with a particular time of day with meals? Um This is all really good to just cover all bases and then vomiting. You want to ask, are they eating and drinking if they are not, how long has it been reduced for any bladder or bowel symptoms, any blood that they're losing as well? Uh, fever also just clarify that for your inflammatory and infectious conditions. Uh, past medical history, often with pediatrics, they won't have too much in their past medical history, but if they do, it's most likely the current presentation is related to that. Um And also ask about any recent illnesses. And I say that for two things, um if they have had any recent illnesses, like a viral upper respiratory tract infection, the pain depending on the site could be related to a ruptured spleen which you want to make sure you don't miss in a child or um the viral could have led to a DKA episode if the patient is known to be a type one diabetic. So these are some of the differentials I came up with appendicitis. DKA constipation is again, very common in Children. Uh UTI could be another thing that has, that has led to this kind of pain. Um reproductive causes like any cysts that are ruptured or any torsion that's happening. Um Spinach rupture, as I said, IBD. So inflammatory bowel diseases, whether it is your Crohn's or your colitis and then gastroenteritis again, very common, but it can lead to patients presenting to Ed as well. And for that, you just want to give them basic, um, hydration advice and depending on just how unwell they are, you might want to decide to admit or not admit them. So this would be something they would want you to include in your management plan as you're working in the ed. Are you going to keep them in or are you going to, uh, make a plan and send them home? So, investigations wise in the station, they could ask you to do an abdominal examination as the focus instead of just talking through the station. Um, and then in terms of investigations, then bedside, you want to do a urine dip, you might want to send off a stool culture, uh take some bloods, your routine ones, but also something more specific like calprotectin. Or if you're thinking it could be a celiac flare, you might want to then send off um, your TTG imaging wise. Um, not very commonly that we do imaging, but for three indications, uh you might want to do an abdominal x-ray for constipation. But if you're thinking an appendicitis, depending on your trust, you might want to request an ultrasound or a CT, then do you want to consider a pregnancy test depending on what the age of the patient is and how likely you think pregnancy could be behind the reason for this pain. Um Now, if someone is very underage and they come in with a positive pregnancy test that would then prompt you to think about safeguarding as well as a side note. Um, management. Again, break it down into your medical, surgical and lifestyle management. Uh in particular, if they are coming in with a DK, you want to consider long term diabetic counseling, perhaps they're not taking the insulin for something. Um Maybe there is an underlying mental health reason related to this presentation. So these kinds of things you would cover and seeing as it's Children coming through, they will often be school age and your station. So you want to make sure you're letting school know as well that the ba the child is off school. So these are just your holistic management points. You want to cover uh any questions about this case or the last one. So someone just asked me about the last one about, you know, would you be expected to give long term management like reducing smoking in an acute setting? So not really, it depends on um how important the indication is to mention it early on. Um So it's, it's fine if you miss it. Um It's an osk setting which is simulated. So if you do uh miss a small aspect, you're not gonna be marked down. It's for the big things like safeguarding. They want to make sure you don't miss those. So case for then um you're the fy one in the emergency department and this time you are seeing Victor Bebb who is a 78 year old presenting with weakness in his legs. Now you'll have 10 minutes to take a history, then again with, um, diagnosis, investigations and your management plan, you brainstorm it and then answer any questions the patient has as well. Ok. So that is two minutes for this case, let's just go through an approach. So with this one, again, very similarly for the history, ask about the onset the pain. Um And also are they having any paresthesia alongside the weakness? Um because that would indicate there is motor and sensory involvement as well. So what I would want to keep in the back of my mind with a case like this is they have weakness in their legs. Is this um related to something a bit higher up like upper motor neuron problem or a lower motor neurone problem? And is this patient known to have falls? Um is did they have any associated syncope, any loss of consciousness episodes as well? Cause that could indicate they could have just had a stroke and now they have residual weakness in their legs. Um ask about the past medical history and this is a good chance to ask about risk factors. So do they have diabetes? Are they hypertensive, do they have af uh are they known to have any previous episodes of such a thing that then resolved, which could then indicate this is a potential MS case. So in terms of differentials, there's lots of different things, but these are the ones I would definitely want to rule out in my history taking. So I would ask about, called equina. Do they have any of those red flag symptoms? Um with MSCC. So, do they have any past medical history of cancer? And now they have a metastatic spinal cord compression. Um Are there symptoms consistent with sciatica where they have this pain and paresthesia that's coming on unilaterally most often and also ask about um, any previous diagnoses of uh potentially querying MS or any relatives who have MS as well. Um You'd also want to ask about fever and those kinds of things as well just to screen for systemic upset, which could actually indicate a spinal abscess if they do confirm that they have a fever. But the other thing also to make, make sure you mention is do they have any previous surgery or any wounds to the back? Because that could then indicate they have Osteomyelitis, which you want to make sure you definitely act upon really quickly as well. Um In terms of investigations, then you would need to do a neurological examination to actually clarify whether it's upper motor neuron or lower motor neuron. So, revise these signs and symptoms again and um, make sure you know which ones are indicating upper motor neuron or lower motor neuron. If you just get presented with one finding in any information you shared in the station, um, do your bloods. So routine ones especially and you might want to add another things to check for your risk factors like your HB A1C, your triglycerides, all of that as well. Imaging most often you'll end up doing an MRI scan for patients who come in with neurological issues um to check for spinal cord compression. Then in terms of management, medical surgical lifestyle, as we've been saying, so does the patient need aspirin, uh pain relief they will need, but especially if you're considering pain relief, you want to consider your nerve blocking pain relief agents like gabapentin, pregabalin, all of those. Um in terms of lifestyle, again, make sure, you know, are they safe to drive, are they safe to work? And with a case like this and actually this applies to everything else we've done before as well, make sure you know, when to escalate early to seniors and know how you would go about doing it. So, in real life, what you would do is as an F one in the ed would raise this up to the senior. So it would be a registrar or a consultant you're working under and then they would then liaise with a different specialty if you have that specialty within your hospital. But if you're someone who's working remotely, you just get some approval from your registrar or your consultant and say I'm gonna make a referral online to the local neurosurgical center for this patient. And then that's how you'd go about escalating appropriately So that's just uh this case. But I wanted to take a moment to highlight what the difference is exactly between Cor Quina MSCC and also your sciatica because this can get very confusing for a lot of people. So as you can see in this image, you have your spinal cord and then at the bottom, you have your corna which are your nerve roots and then they all exit through their respective phenomena and they then combine to form your peripheral nerves. So if anywhere along the spinal cord above the cord corna, you have a compression, it will be a spinal stenosis related to whatever the pathology is. And if it's a cancer, you will call it metastatic spinal cord compression. But if a patient has a compression in the coral quina region, and this is not due to a cancer, you will call it coquina because that's the relevant area of the uh impingement. The diff the, the the reason why I mentioned this is because you have different signs. So your spinal cord will have upper motor neuron signs, but your cord equina will have lower motor neuron signs. So one of the questions which we did actually get asked in our o is uh for it was for a different case. They said, why is this case, a metastatic spinal cord compression and not cordia equina? Um So the reason was because of the examination findings and also given the history and the location of the compression on the uh MRI we were given to interpret. So just keep these things in the mind. And then I think another question they also asked us for that case was why is this not a spinal abscess? Uh because it just says it's a mass lesion. So the reason was you can explain that, you know, on the blood test, we've not noted any rise in inflammatory markers. The patient is systemically well, their new score is zero. They're not scoring for any fever. So these kinds of things you would then use to bolster your wheezing behind your differential diagnosis. Um Can you show the previous light piece? Yes, I can let me just finish talking through this one. So that's the difference between your spinal cord compression and your cord quina. Now, you also have sciatica, which is a peripheral nerve impingement. So this is called a radiculopathy. So these three terms you really should know for your neurological stage. So, all right, there you go. That's the last slide. Any questions about this one? OK. I'm gonna say that as a no, if there are any questions, just pop them in the chart. So, um I would really recommend using BMJ best practice. I thought this was a really quick speedy way to revise through my conditions. What I need to ask in history and examination, uh what investigations I need to order in the management plan as well. So I'd really recommend this for quickly revising you for content because there can be so much to cover for all the six different specialties and rotations we've done. So any questions about this station as a whole? So can you get MSCC at CH Corna? So it's in the name really, it's metastatic spinal cord compression. So you can have metastasis near the corna, but you can't get a spinal cord compression. What you would then say is the cord quina is being stenosed due to metastasis in the region. So you would have to say the full description. You can't call it MSC. Always ask about the situation at home if it's an org case. Um It's good to ask um especially because, you know, the of often the woman is coming by herself. So just ask who's at home in case you need to uh have any arrangements done for that? Ok. Amazing. So I'll still be in the background. Any questions just pop them through and I'll reply on the chart, but now I will hand over to Doctor Shady Kamande. Hi, I'm she, I'm one of the f ones working in Leicester. I've just been asked to talk to you about how to assess the deteriorating patient. It's one of the stations in your oy and I'm just gonna try and take control. So the layout of the station is you'll have about eight minutes to perform your A two assessment. So there'll be one of the, you know, the, um, clinical nurses that are at your clinical skill station, there'll be one of them there and there'll be a model of a mannequin and you'll walk in and you'll sort of have a sheet which will give you a background of the patient, which is sort of your, the, the situation on the background of the patient. Um, maybe a drug chart and there should be a paper BNF as well to help you with the treatment summaries. So you'll go through a, a three assessment and you'll ask for observations and examination findings and that she'll tell you them, she or he will tell you them as you go through the A three assessment and you're sort of expected to solve problemss as they come along and treat abnormal findings as they come along. It sounds like a lot to do in seven minutes. But because you're sort of asking for it and it's not like you have to wait for the oxygen saturations or the BP, they'll tell you the result um immediately. So it will go quite quickly and then in this eight minutes. So maybe it'll take six minutes to go through your A two E and then they'll move you on to do a clinical skill. This clinical skill, it's unrealistic that after your A two E, they'll suddenly get all the equipment for the clinical skill. It'll be there ready when you go into the station. So you'll kind of have an idea of what you'll be asked to do before you actually get to it. So you'll have time to mentally prepare yourself. Once you've done that, you've then got 8 to 10 minutes to interpret investigation findings and then do your sbar to a senior. So it sounds like a lot. But I made a little list of the clinical skills that I thought could come up. It shouldn't be anything too crazy. It'll be something that you've done in your docs and something that you would have seen during your apprenticeship. So, stuff like airway insertion, giving oxygen ABG SB punctures cannulas. So I think someone just asked a question, the skills always come after the A two ei think the skill would be after your A two E not during it. So it doesn't interrupt the flow of your A two E assessment and you can sort of complete that and then they'll move you onto the skill after uh other skills could be IV fluids, blood glucose or just prepare yourself for just the BLS measures and the choking. So the high and the black back slaps make sure you know how to do that. I think it's unlikely that you'll get a S in your A two E station and investigations. Realistically you'll have two minutes to do your investigation and an sbar. It's not gonna be anything too crazy. It'll be a chest X ray, abdominal x-ray, ABG S or VBG S blood results and EC GS, I think the main thing for the station is, oh, and I've got some potential scenarios that we'll, we can talk through. But the main thing for the station is just as long as you've got your A two E structure and you sort of go through it, step by step, your ABCDE and you show that you're safe, that you're thinking in a safe way and you're able to stabilize the patient and then you are able to do the skill in a safe way. You don't necessarily have to do the skill successfully. Because realistically in F one, you won't get the bloods or the ABG or the cannula the first try. Um necessarily. So I didn't get my skill, I didn't do it successfully. And I know multiple other people didn't do it successfully. I think in the moment I panicked because I thought that meant I failed the station. But it doesn't, as long as you're safe in terms, it's the same with the investigation. This goes for all your stations. If you can't interpret 100% correctly, don't worry about it. As long as you're sure that you're able to do your, you know, the A two for the abdominal x rays and the chest x rays as long as you are able to interpret in a structured way and know that you're sort of thinking in a, around the right lines or that you're able to refer or escalate to the correct person. Nothing has to be perfect. Uh, just carry on with the station and move on to the next station after that and just put it out of your head. If something doesn't go. Right. Some of the scenarios I thought could come up. So these are all the ones that I could think of. If you can think of any others that aren't on this list, then please pop it in the chart. But I thought anaphylaxis could come up asthma, opioid overdose or any sort of drug overdose, vomiting, stridor, if they're choking or they got a foreign body, then again, co PD and then all the respiratory like pneumonias, P es pneumothorax, it could be hypovolemia or sepsis. Make sure you just know your tachyarrhythmias and bradyarrhythmia guidelines. I think you did them in your als course and the acute Coronary syndrome and mi hyperglycemia. So DK and H HSI think you should be able to ask for the guidelines because that's what I would do in practice. When you've got a patient with, with DKA or query DK, you just go through the guidelines. You're not expected to remember every single treatment summary. Um head injury, just know the criteria for a CT head seizures, seizures is a good one stroke, hypothermia, hypo or hyperkalemia, hypoxia. Then we got cardiac tamponade, any sort of hemorrhage and just be aware of the major hemorrhage protocol, urinary retention, pericarditis, acute heart failure, sepsis, and hypovolemia. So when you're sort of practicing your, a two stations, just make sure you're really good at going through it and you're really slick at the examination and then when it comes to the further steps, make sure, you know, the initial treatment measures for all of these little emergencies and you know what to do and you know who to escalate to. I think in the moment it'll be a bit mean. I think Aussies are quite a high stress environment. Sometimes you shouldn't be expected to remember every single of these treat one of these treatment, summaries off by heart. There will be the BNF, just make sure you know where to find the treatment, summaries in the back and not to ask for the guidelines or to say I'll ask my senior about further management if you can't think of it in the moment. Did that make sense? Is that OK? Any questions so far? Ok. So here are my top tips for A two es. So I just finished my general surgery rotation and I've just moved on to respiratory. So I've done a lot of a two ESI think in the moment when you see an unwell patient or a patient that's scoring. It's kind of tempting to just call for help, call a senior, but often, especially when you're on call, they can't always get to you immediately and they will tell you to do that A two E and get a good background of the patient. So if you're panicking, don't worry about it because it's actually quite a good structure to use. I found that when I didn't know what to do and you feel a bit helpless sometimes it's really nice to have that ABCD. E just go through all the steps and it's not just the examination, it's also the initial stabilization measures for your patients. So you're treating the problems as they come along and you're stabilizing the patient till a senior gets there. When someone looks really unwell or unconscious or like they're about to become unconscious. I always, just as I'm walking towards a patient, I just ask someone next to me to get the red arrest trolley, ask someone else to get the notes for documentation and ask them to either get an ipad or prescribing chat chart and start a set of observations. I know when you're where you ask for them bit by bit. But realistically, you know, they've got the obs machine, they'll do them all at the same time. So that'll save you a bit of time if someone else is getting all that ready. And in that moment, you're also delegating to other team members if you're working just for when you're starting work and you're doing these A two es or dealing with unwell patients. I know it's a bit tricky sometimes when it's an acute situation but try and pull the curtains just to give the patient a bit of privacy, especially when you'll be exposing them. Like I mentioned before, just try and delegate tasks to your team members when you can, you know, um I always run my own GS. But if a patient is really unwell, you can ask someone else to just run it so that you're with the patient and you can ask someone else to call for help. If you don't, if you've not got a senior with, you just remember to introduce yourself to the patient and the rest of the team, especially when it's your first week or two weeks. Just make sure people know that you are the doctor. Um, like I said before, just treat abnormal findings as you come across them. Don't try thinking ahead too much because I think that's when you get muddled a bit. Uh, UR guidelines are always available and if you stay in Leicester next year, then we have nurse center prescribing. So if you start type in hyperkalemia or asthma attack, it just comes up with a bundle so you can just click it. Obviously you can't do that in your ski, but it's good for future management. Yeah. So what I was saying before about the, um, before calling a senior getting the A two E, when you do your sbar and your, in your a of your sbar, you'll be telling them what you found in your A two E, you'll be sort of going through the investigations that you see because they might not have the chest X ray, they might not be able to look at a computer, the chest and they won't have the ABG or the BG, especially. So they'll rely on your examination findings and your interpretation of the results to determine further management and give you a plan. So it's really important that you have, do a good examination and you present it in a really structured way so that your senior kind of gets a good picture of what's going on on the ward if they can't be there in person. And I think documentation is really important, especially when you're not gonna be working a day shift if you've just been on a night. So for the day team to see that you've done that A three and it makes you look good as well to show that you've done that full assessment for the patient and documenting w what you've done if there's a plan from a senior, make sure you make it clear that this is the plan from the senior. And in your further steps, when you're telling the examiner, just say I'll document everything. OK? This is some of the marking. I don't think it'll be, I I'm sure all of you will get these marks. It's just obviously, when you are about to go up to a patient and you're doing a two week, you will check that they're breathing and they're alive first and they've got a pulse before you go through the whole assessment in detail, ask for observations when needed, interact with the clinical staff appropriately. I'm sure you all do that and teamwork skills. A major thing of teamwork is delegation. Also making sure everyone's comfortable with the task, you've delegated to them and make sure that they know that they can sort of ask for help or another team member can support them if they're struggling a bit. Yeah, just perform the skill, be confident with the skill. Like I said before, you don't have to get it. Uh Just do your best and identify all the positive findings. Just be systematic, prioritize the information in your s, you can't talk through everything you've done. Just give the main points and appropriately manage the condition. Yeah, this is just the excellent mark scheme which you'll all get. And so I thought you've done it in your fourth year os you haven't, you, you've done an A two E before and I'm sure you all know how to do and you're a bit familiar with it. So I thought we could try a case first and then after the case, we can talk through the different steps of the A two E. Is that all right? OK. Oh, so I've got three cases. I think they're gonna, we'll, we'll go through one case and then the other two we can pop on. I think they're making a bank or something. A case bank which sounds very nice. So, should we go through the unconscious patient? So this is what's gonna, this is what the case is. So you're the f one on call and the nurse informs you that her patient is unconscious in a stair in his chair. What are your next steps? Any ideas on what you'll do? Uh The other cases are going, coming up over Christmas. You've got an unconscious patient. Yeah. See if they're breathing. Yeah. You're, you're hoping they're breathing. They are, they are breathing and they've got a pulse. Yeah, you've done your quick ABC. They're breathing, they've got a pulse. Now, what are we gonna do? History? Um The patient's unconscious. So I don't think we can take a history of that. That's what HX means. Yeah. Um Before airway, if a patient is unconscious, I usually just try and wake them up just maybe like um wake them up. It's the AP scale, isn't it? Yeah. Get some help call for help, get a nurse there. Yeah. Um Someone's mentioned, get them out of the chair. So the patient, so this is what we do before the gator, which is equally as important as the gator just making sure that you've got the right environment and the right equipment that you can go through. Yeah. So all saying good things. So on the AFP scale. So they're unresponsive to sternal rub, but they're breathing. So, because if you, if they just rouse with, when you shake them a bit, then they're not technically unconscious. So get the patient in bed and start a set of observations. You don't want an unconscious patient in the chair, you don't want an declining unwell patient in the chair, just get them in the bed, it'll save you a lot of hassle and just start these set of observations immediately. I don't think anyone's mentioned this before. I don't think anyone's mentioned in the chart. Um If there's an unconscious patient and they're unwell and you're an F one on your own, you can put out a Perret call. So it's not an arrest call, it's a Perret call for sort of unconscious, very unwell patients. Someone said get the crash trolley, that's really good and call for help. Someone's also said get some nurses there. Yeah, and check glucose. Yeah, because I think usually when patients are unconscious, um That's the first thing you'd want to do like we mentioned before, get a prescription shot. So you can actually prescribe stuff. And also it's really important because then you can check the allergies. You don't wanna have an unconscious patient and give them something they're allergic to. Yeah. Patients, notes, ask someone to start documenting notes are also important because you can check if they've got respect form or not. This one doesn't like a lot of surgical patients pull the curtains and just check these three forms of ID as well. Don't forget even during your two e to do the basic stuff. So, always check ID and get some help and get all the prescription ipad charts and check allergies as well. Is that all? Ok. So now we're gonna go through our A A three. So what we're gonna assess the airway? Oh, no, we've got patient background. So the patient, you, you've got this from reading through the notes. So someone's told this to you while you're doing a three. So he's a 63 year old man. He's had a laparoscopic right hemicolectomy for bowel cancer three days ago. Um, you, they had a quick flick through the operation notes. There were no complications during surgery. No respect form in place. And he's got a past medical history of COPD, high BP, bowel cancer, diverticular disease and high cholesterol. And he's on statins, Nitrol tiotropium, amLODIPine, Darin, Ondansetron and Oramorph P RN. He's not had any of his Pr Ns today and he's got no allergies either, which is good. Are you all happy so far? Any concerns? Right. So, should we start airway assessment? So what are we gonna do for the airway? So we've checked it. He's still unconscious. What are we gonna do? Yeah. In. So which one are you gonna go for? Yeah. And before the airway agent is a maneuver that we do for unconscious patients to sort of open up the airway? Yeah. Ok. H TCL. Oh yeah. Head tilt, chin lift, nasopharygeal area. Yeah. So patients unresponsive, they're still unresponsive and no response to sternal rub. So you do your head tilt, chin lift and start looking inside the mouth, the obser, they're starting all the observations. They're getting everything ready and all of a sudden your patient starts vomiting coffee, ground vomitus. So, should we get a na, so we're gonna get a nasopharygeal airway and anything else we want to do in terms of a, for management? Now. Jaw thrust. Oh, not, no, not now that the patient is a bit more visable. Yeah. Suction. Yeah, that's like a really big thing. Um, it's be, it's always behind the patient's bed, there's a little suction machine and if they're vomiting lots and lots and lots, what can we also consider doing? Yeah, left lateral position. So left lateral position and suctioning if the vomiting and NG. Yeah, perfect. So all of the, all of this for the airway when someone's vomiting, the NG tube, left lateral position and suctioning is all to prevent aspiration, pneumonia and then choking on their vomit contents and we'll do a nasopharyngeal airway. I think if we put an oropharyngeal when he was kind of conscious and he's vomiting, it's just gonna make the vomit, it's gonna irritate his airway more and make him vomit even worse. So once we've kind of got our airway, we reassess with every step, then we'll move on to breathing. What do you sort of want to do in terms of breathing you can just ask your nurse for the ultrasound. Yeah. Oxygen sats and respiratory rate. Yeah. So his oxygen saturations were, yeah, Tria. Yeah, always do an inspection. Every step. Just have a look at the patient. Yeah. Per chest expansion, left side or vomiting. We were always just told to put terminal on the left side because then the vomit contents aren't going down into the airway into the lungs and it can sort of just come out a bit more. I'm not sure why it's the left and not the right. But these are your breathing assessment findings. So, respiratory rate is 20. So it's OK. Oxygen saturation is at 85% on air. The trichia central and chest expansion is equal bilaterally. Mel oh The patient was a bit arousable when he was vomiting, he was unconscious. Then he did the head tilt and then he became a bit more conscious. Um trio central chest expansion equal bilaterally. So when you percuss the chest, oh nit's just replied to the question about the left side. Oh, it can be either side. Air entry is equal bilaterally and you've got a bit of an expiratory. Wheeze. So what are sort of the positive examination findings on the breathing assessment? And what do you want to do? Now, someone's mentioned already about 15 L of oxygen through a non rebreathe mask. Yeah, he's got COPD. So I'd start them on the salbutamol nebulizers. Is there anything else you do apart from give oxygen if there's up to 85%. Yeah. PrednisoLONE. Yeah. So I on my own calls, whenever a patient had low, sat out of the blue, I was always told to do an ABG and we could also do a chest X ray if you're worried about sort of air entry, but it was equal bilaterally. But I usually just order one anyways because I never know if my examination findings were a bit off. So you can do an ABG portable chest X ray oxygen and back to back nebulizer salbutamol. So you've all said that anyways, um, in terms of the prednisoLONE, whenever someone had an asthma or COPD attack, I'm not sure if it was because I was on the surgery wards, but often the prednisoLONE wouldn't happen once the patient was a bit, um, more stabilized. Ok. So circulation. What do you wanna do now? Observations in terms of c refill? Heart rate? Yeah. Mhm. Start your hands and move upwards. Ecg Yeah. What bloods do you want for blood count using these Ts and CRP? Are there any other bloods you'd want? Oh, yeah. Someone said cross matching group and safe. So he's POSTOP and he's vomiting a lot. So you'd want to just do a cross match and group and save any patient that's POSTOP. That looks a bit funny when you're doing the buzz. Just do your group and saves as well. Ok. Is that it for. Do you know what Cannulas you try to put in if a patients during an, a two week, if a patient is unwell. Yeah, the large bore Cannulas they never have in the store room. They always in the arrest trolley. Yes, I think it's orange or gray green. Trying to think green, maybe green as well. Ok. So this is what you see on circulation. The heart rate is about 100 and four and the BP is low 70/40 capillary refills, four seconds and the peripheries are cool pla pale and CMM. Heart sounds are normal. There's no raised J BP or peripheral edema. His mucous membranes look really dry. You can see a pink cannula in situ and you've taken these bloods and you've done an ECG as well. What else do you want to do in terms of management of the circulation? Now, think about what looks off. Yeah. What are the R fluids? Yeah. Sodium chloride. For how long? Yeah. And don't forget in terms of circulation about the fluid balance assessment. It's a really important part of your A two E especially when you're giving repeated boluses. You don't want to overload them and make sure that they're um passing urine as well. This doesn't necessarily have to be done through a catheter. It can be. So this patient's POSTOP. So I'm sure you'd have a catheter in anyways, we can check, but I don't think every patient that needs a fluid balance assessment would need a catheter. I think that you can monitor it with that one. And if you can avoid using a catheter, then it's one less source of infection and trauma to the patient, especially when they're already unwell. But if they're not able to sort of walk immobilize the toilet and you're not able to measure it that way, then maybe a catheter would be more beneficial. Or if you feel like they're going back to, to surgery. But no, you don't need to insert a cath for every patient. Ok. D disability. What do you do? Someone's already mentioned a while ago that we would do blood glucose at the beginning. I think if I had an unconscious patient, I'd probably just get someone to do the finger prick blood glucose. Yeah. The au that's really important part. Usually when I'm doing like my, on the nights I just document it as an A two. Even if a patients come in with like tummy pain, they look, ok. I'll just do like a airway patent and then I'll do a lung and then I feel a tummy and then heart sounds and I always do an AFP scale just to say that you've done that part of the assessment. Yeah. Temperature pupils. G CS. What else would you check during disability on the patient's record? They're a bit unconscious drowsy. Yeah, opioids just make sure they've not had like a bunch of opioids. Yeah, the drug chart is really important. Just check allergies, check opioids. I have seen, um, on surgical admissions that every patient no matter how old they are does get all them off on their P RN chart. So, just keep an eye out for that. Um, ok, gcs is 11. So nothing to do anything crazy about. But they're still a bit drowsy. They're verbally responsive. Just not quite there. Blood glucose is actually fine. The pupils equal and bilateral and the temperature is 36.3. And we've already reviewed that drug chart. They've not really had any PNS of that or off. So, in terms of management, is there anything we're gonna do for the disability? No, I think one thing when I was doing my A two is like when with really unwell patients that I've always seem to forget about until the registrar told me was pain relief because when the out of it, they won't be necessarily able to ask for their PRN. So make sure that you're keeping their pain you're keeping on top of that pain. This is your G CS scale. Um Yeah, just try and remember it as much as you can. I think you probably do need to know it for finals. Yeah, just give us some analgesia. You can give a high dose. I mean, he's vomiting coffee ground vomitus and he was unconscious. So he's probably in a bit of pain. Um, what's the last step exposure. What do you wanna do for that? What part of his body are you gonna take extra care to have a feel of? Is it safe to assume he's in pain though? I don't think 10 mg of Oramorph is gonna do anything to a patient. Um, if they're unable to ask for pain relief, I think it's probably, I was told by a registrar it's safer to give it to them and have them in pain. Yeah. Assess the wound site, check the abdomen, pr bleeding. That's good. So you do your head to toe assessment. He does already have a catheter. So you don't have to worry about whether we need one or not. Um His abdomen is hard, distended. He can't hear any bowel sounds, calve soft and tender. Um let's say there's no pr bleeding. What do you want to do now? And sec? Yeah. So you've already popped out. We can pop an energy tube in giving fluids. Yeah. Escalate as well. Is there any imaging you wanna order abdominal X ray? Yeah. Yeah. So the main thing is once the pa once you kind of finished, got to the end of your A two ei think now this is the time where you would reassess quickly, just make sure that they're still stable cause the aim of the A two E is get them stable so that you can quickly call your seniors to come and review them. So he, he's got an angio tube in, he's speaking, the airway is patent, just try and sit the patient up. If you can, it's probably more comfortable than being in the left lateral position. Respirate is fine oxygen saturations up. So I think once they're about to a normal level, you can switch the ventura mask. Um air entry is equal bilaterally as wheeze isn't there anymore? BP is a bit low. So you can give another bolus, then you can give up to 4 500 mL boluses up to 2 L. You can give, he's looking a bit more pink and he's looking a bit more lit. Everything else is looking a lot better. His tummy just still looks a bit hard and distended. He's still not got any uh bowel sounds present and his calves are soft and nontender. OK. So are you happy so far? Yeah. OK. Your patient, let's just say your patient is now stable. So you've done your part now it's time to escalate onto a senior. This is the investigation results of the VBG. So I know we mentioned ABG before, but I've, I've missed a lot of them. You're not necessarily gonna get them all the first time. So if I can't get an ABG, then I'll just do a VBG instead. So what's definitely standing out to you about this VBG? Yeah. Also whenever you've got an unwell patient and you're on like general surgery, the reg always wants a lactate. So try and get a g before you call them. Yeah. Acidotic. Mhm. Could sepsis be going on? Um, they're not spiking a temperature and we have to see if they've got an infection first. We'll check their blood markers. But apart from sepsis, I think, what kind of thing are you worried about? More than sepsis at this moment? I think it's always good with bowel perforation. Yeah. Yeah. Bowel obstruction. I think sepsis is always good to keep in the back of your mind, especially when a patient's scoring a bit. Yeah, bleeding bowel obstruction. Mhm. So you've got some differentials differentials in your mind. But the main thing is this patient probably needs a scan and a senior review. Yeah. All good, all really good differentials, all the kind of emergencies that would require escalation. So the situation would be what you got called to see the patient for the background would be the background that we had for the patient. And then assessment would be your A two E your investigation findings and recommendations. I don't, I think it might be a lot for you to type out if you had to go at the sbar. But would anyone like to do you want to have a go someone do situation? Shall I go back to the original slide? So if I was doing the sa I'd probably say like introduce myself, say where I am and say I've got a patient that I'm worried about that I've been to see because he was unconscious. Um He's had a right hemicolectomy three days ago for bowel cancer. And then you just go through a three what you did? I think during your OSC it'll be a lot to remember at first. But I think once you do it and once you're going through all the steps, it'll be easier for you to hand it over recommendations. Like, oh, I've done this, I've put an NG tube in, we started IV fluids. Um What else would you like me to do or could you come and review this patient? If you want them to review the patient, it'll depend on how worried you are and what the situation is. This is obviously quite an extreme situation. I don't think your actual A to B will be this. The patient will be this unwell. Yeah. So knowing who to is really important. So I would definitely call the surgical registrar. So sorry, my wife, I just cough. Um OK. Is that all? OK? I think n just answered your question, uh learning points, make sure you know, to contact your senior. So when I got called to see this patient, I was really scared that this was like my second weekend being an F one and it was really scary. But I think having that A two E structure really helped because I just went through the steps. The nurses know where all the equipment is, which is the main thing I didn't know anything was and they are able to help you. They're all trained in BLS and they've all done this multiple times before. Um, making sure you know how to contact your senior. I didn't realize that, um, on our handover phones that the seniors number was in there. So I kind of didn't know how to get a hold of them. Um, it's like I said before, like, try and get an A to e before you call your senior. But if you're not confident in managing the patient yourself, then you're absolutely within your right to call for help or escalate to someone. It's whatever you feel comfortable doing as well at the end of the day. And also recognizing the limits of your competency is really important too. One thing that I realized from this was if a patient is deteriorating, the nurses kept telling me like you need to call the family, you need to call the family. And I didn't realize that it's, it is important because they in with surgical patients, they do deteriorate quite quickly. Um They're always a full escalation. They were always quite well before they had the operation and these complications. So you definitely need to call the family. So they have time to come, come and visit the patient, especially if they're declining quite quickly. Um One thing I saw was that a lot of patients who needed respect forms didn't have them in place So make sure you push the dating the seniors to do that as well and hand it over documenting we talked about was really important and handing over, always check in with your team members afterwards and debrief with them and your senior for like further reflection and learning. I don't think you'll be expected to handle like an unconscious patient. I made the arrest call to the wrong hospital. So that's why I didn't have my per arrest team, but usually you would have one there to help you and go through the um sort of steps and you'll just be helping. It'll usually be sort of unwell patients on your night shift that just have a bit of tummy pain problems with their drains. Um A bit breathless, breathlessness came up a lot or chest pain as long as you know, to go through the steps and know what to do, what to order, who to escalate to. There's always a senior you can call. Ok. So that was the case. I've just got some notes on a three, I'm sure you know them all. Um, we do, we can just skim through it quickly. So like I me mentioned before, make sure you introduce yourself to the patient. Check their three forms of ID and check, do your like quick a ABC check that they're breathing and they've got a pulse. So if they've got a compromised airway, just look inside the mouth, just have a look inside to see what's going on in there. And you can do a nasopharyngeal airway. If they're conscious, think if they're unconscious, you can do your head tilt, chin lift in the oropharyngeal airway. If they've got vomit or secretions, suction, left lateral position or the right lateral position, if they've got anaphylaxis or you have a suspicion of it, just give them the adrenaline and then reassess after you've done all your airway m measures, breathing, your respiratory rate should be between 12 and 20. Um oxygen saturations should be between 94 to 98. I think COPD if they retain as it can be a bit lower, they should be, they should have the hypercapnic model on the um S chart on the online one. So it shouldn't flag up if that's been done. So if it's low, just do an ABG administer oxygen, sit patient upright. You know, all this like the inspection check, the trach and chest expansion, percuss and auscultate and then reassess once you've done all your measures, I usually have a low threshold for doing a chest X ray because I don't know that I wouldn't, wouldn't miss something on examination. So I'll just order if a patient looks like their, if their respirate is going off or the oxygen saturations are going off. Um heart rate should be between 6099 I mentioned before, like the Brady arrhythmias and the tachy arrhythmias, just make sure, you know, those guidelines because we have had those on the ward that you've had to manage, that we've had to manage BP with BP. Just make sure you look at the trend because some patients run a bit low in terms of BP. Um if it's low, give a fluid bolus and I was sort of told that try up to 4 L, not 4 L2 L of boluses. So four boluses and if they're not responding at all to all the, all these boluses you have to consider in it or senior input, I think it has to be a senior that informs it anyways, fluid balance assessment is really important. I used to always forget this when I was doing like a twos in med school general inspection, the temperature JVP, heart sounds edema and reassess. I think there's always that fear with, especially with patients with heart failure of overloading them. I used to get really nervous. I had the one of the meds on call about this and they said you, even if they've got heart failure, you can give them um repeated boluses if the dehydration and hypovolemia is more harmful than the risk of overload. So if they're not getting enough um fluid around their body to maintain the circulation to their organs, then that's more harmful than overloading them if they've got heart failure. So it's that balance. Um and you can give fluids if they've got heart failure. Yeah, it's the wide bull Cannulas. They never have them on the wards. They're always nearest trolleys. Blood tests. Yeah. Just do everything. Just do as many as you want to do if they've got chest pain, do a troponin. I think you have to do a repeat one, a few hours after, uh, toxicology screen. I think this is a urine test as well. And mast cell tryptase for anaphylaxis. Then D diers if you think they've got suspicion of pe um if you think someone's got a pee, you have to do the ECG chest X ray and D dime as quickly. So then you can sort of get all those done and then get the CT pa vetted as well. After uh ECGS bladder scans, I think it's, if it's over 500 mL, you might need to consider putting in a catheter um pregnancy test, urine dip MC NS. Yeah, we talked about catheterizing and fluid balance. Make sure you know about the major hemorrhage protocol and blood transfusion. We actually do have to transfuse patients quite often. Um just a unit or two if their hemoglobin drops, especially postoperatively and then reassess again, the disability, just do your happy scale pupils. Make sure you check the drug chart, blood glucose and if it's high, just do your ketones. If it's low, then just give them the um Gluco gel or whatever you've got on the ward. If GC sGC S is less than eight, the anesthetist, hopefully, if the G CS is less than eight. You would have put out a per arrest call because the anesthetist is part of the arrest team anyway. So, they'd be coming on their way. CT head analgesia and reassessed exposure. Yeah. So, on surgery we did lots of abdominal examinations. Don't miss the calves. Just check any lines, drains or catheters. You don't want to be on the phone with the surgical edge and they ask you if they've got any sort of drains and there's one in their back that you've missed. Um, just make sure you check everywhere, um, for any of those because they're also potential sources of infection. Yeah. Temperatures think sepsis. I sort of get a bit wary when the temperature is above 37.5 because that's sort of a low grade fever and if it's sort of creeping up and, yeah. Um, like I said before, just have a low threshold for thinking of sepsis cultures or swabs and then reassess. I think that's the end of the presentation finished quite quickly. Any questions about a two E, I think if you try on your apprenticeships, you'll have your medicine one and your surgery one if you try and go with your F one on call and if there's an, obviously if they're not too unwell, if there's a patient that's a bit funny or is a bit breathless, breathless or got a bit of tummy pain, maybe ask if you could do the A two E because it'll help you practice going through the steps. And then if you've done the A two E, you've looked through the notes and you've got the, a bit of a history from the patient. If you also try and do the sbar to the senior as well, that will be really useful because the more you do it, the more you'll kind of get an idea of what questions they'll ask and then you'll start to include them in your sbar. Um What else for the skills on the ward, especially during a two weeks. So I had another patient who had an opioid overdose and his peripheries shut down. Would you still do a DDIMER if they have a well score greater than four? If they had a well score greater than four, I would do a chest X ray, ECG and then the, I would just do the D if I was doing bloods because I could just do them at the same time. But I don't think you need to according to the guidelines, I don't know if that's correct. I think the main thing is just to get the ECG and chest X ray out of the way so that you could get the CT P because that's a def definitive diagnosis for pe When would you call it ti feel like it is when a patient's observation, like BP is consistently low despite fluid boluses. So usually if you give someone a fluid burle, that blood blood pressure would respond to it if they're not responding to that. If they're not responding to, if their sats aren't increasing despite oxygen or they're having oxygen requirement, that's quite high. Yeah, I think D DIME is one of the inflam markers. And what was I talking about it? Yeah. So it's, if they're not responding to the fluid boluses or the oxygen saturations are consistently low, then it's definitely something to consider. But I think a senior, hopefully a senior would be involved by them and they usually are the ones to call it to you. Um Before you do that, just make sure you check that the patient's not for ward based care or they're not for, they've got a, just check their respect form because if it says they're not escalation, then you've called it over. It doesn't look great. Um What was I saying? Yeah, with the patient with the opioid overdose. So his peripheries had shut down and we couldn't get an ABG or um we couldn't get an ABG for the blood class and its oxygen saturations are really low. Um And first I think my core trainee was calling, I was actually calling it and I was the only doctor there and there was a nurse there and she said, oh, like you need to do the femoral stab and I'd only done one ABG I think in like third year before. So I said Oh, I'm not gonna get it. And she said no, you, like, you will get it. You, um, if you try you'll get it. And she, like, gave me a lot of confidence. She was, like, just do the needle, put it in and you'll get it and I didn't get it. But I think with those sort, sort of skills with a per rest and especially as a medical student with the airways and all them, you might be more wary of doing it if the patient's really unwell because you, you want someone more skilled to have a go. But I think you are ok to just try because you never know you might get it. And these aren't things that you'll be able to practice on well patients. It will always be the unwell patients that need these measures like a femoral stab or an airway. So or chest compressions. So please try and have a go cause you probably, yeah, you, you have to think you'll get it even if you don't, it's fine, but just think you'll get it and maybe you will. What else if a patient has COPD, do we give 15 L of oxygen initially? If the SATS are low? Yeah, I think so because the hypoxia, if the oxygen SATS are that low, then I would just give 15 L of um oxygen and then you can switch to a venturing mask once the saturations are coming up a bit, it's like it's the same sort of reasoning with the BP. The hypoxia is more harmful to them than the CO2 retention in that moment. Ok. I think I finished my slides. Yeah. Like I said, it's sort of a bit before the A two as well. Just making sure you've got your rest trolley, all the notes together and the ipad for prescribing um delegating, we said, make sure you introduce yourself, treat abnormal findings as you come across them. Um And I think you join your OS station, you should be able to ask for the guidelines. Uh We talked about S one documentation. So do you feel OK to assess a deteriorating patient now, because you'll be on your apprenticeships, won't you? So you'll be able to have a go. Yeah, you can do it. You're fully capable. You're 50 years. You are absolutely fine to do an A two E, what type of airway agents should we give? So there's a nasopharyngeal for sort of patients that are more conscious and the oropharyngeal for completely unconscious patients. I think this is maybe right now. OK. I think I'm done then. Thank you. Thank you very much for the very lovely a three session. Shey. So uh yes, that is correct. So this is the end of our session, but we'll hang around for a few more minutes. If you have any more questions, we'll answer them in the background. Uh But just to let you know, our next session will be in the new year. So keep an eye out and we'll again be posting on Instagram, Facebook and email will be sent out as well just to remind you all of the next upcoming session. But in the meantime, if you can all, please fill out the feedback link, um it will mean a lot. It will show us how we're doing with the course and the feedback will be really beneficial for our learning and going forward from here with our teaching careers as well. So I'll leave it on here for a few more minutes. Any questions you have just pop them in the chart, feedback link and chat. Yes. Just give me a. Are you able to access this Phoebe? Ok. No worries. Um I just saw a message, um, someone just asked, when is it appropriate to call slash involved dart team about a patient? So I think they get so on in the, when I was on surgery, they'd get notified. I think if a patient's EWS was over seven, so they'd already be aware aware of that patient, but you could bleep them if you're worried about patients suddenly deteriorating if they're scoring like over five or more, and you don't think you're able to stabilize them on your own or manage them on your own. Um I would usually go to my senior first try and call the surgical registrar or the med reg and then if they think calling, that would be a good idea, but it's just an alternative person to call if your senior can't get there in a sufficient amount of time, especially if you can't get like ABG S or access or anything like that. They're also really helpful and really friendly. Um, I've, so I'm at ward 17 at the Glenfield. I've not got a fear attached to me. So, if you ever want to show up, I'm happy for you to do sort of a two es we do our own ward rounds, the juniors do our own ward rounds and we see our patients in the morning. So if you want to pop in, I'm happy to let you see patients on your own and come up with plans and there's loads of us around, aren't we? Nn is in Manchester, I think. But there's lots of us in all the medicine wards in Leicester, but I'm at ward 17 if you want to pop in. Yeah, don't worry about your placements just turn up somewhere. And as she is saying, there's lots and lots of different medical wards, surgical wards in Leicester as well. So we have three hospitals which is much our privilege. Um The thing for the peri arrest call or crash call. So it's the same number. It's double two, double two. If a patient is unconscious, then I would just put out Perret call. Um especially if there's no registrar or senior nearby. Just just do it, it's just safer. Um, the whole team will come. Um, if you have a chance before putting out a crash call, if you have a chance to quickly check the respect form, then please do that as well. But you can still put out a call. There's no one's gonna get annoyed at you for putting out a call. It's the safest thing to do. Um, just make sure you say which hospital and which ward exactly in which level? So they come to the right place.