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ready. That's the low. Oh, you were? Oh, like, um, I don't do you hold on going. I'm sorry. I wasn't speaking to him like you're right Speaker. A look. I don't think you got to turn to speak up for non school. Come back on to make for fun. Part of the recording does this not? This is the pre life. Better we'll get recorded. It's on the life bit from a no shame pre life of me. Oh, 10 days. But we're pretty life. Uh, please. You were pretty life. But I know I can't hear you again because my stupid speak is not working. You know, there were lies. They speak again. Hello? Hang on. I made a slide for this. Not being absolutely used to it after a few months. Laptops because there we go. This is why I have this slide. Just ready to go now. We are currently life. Yeah, I thought we were. That's why I've got this this slide ready. I have sound available for my laptop, So Okay. Do you want to test your slides? I think, but people can see them then I just just slide. I don't know. Last tree. Okay, We can see any questions can build slowly and you can see just the presentation, not the m. Just the presentation. I can't see any of the weird stuff on your desktop. There might be cool. Puff it. That's what I wanted to know. Yep. And I'm going to take back over to put my shop interest lies back up. Happy? Yeah. Set up for those few who are in the session. We will start in about seven minutes. We were just ensuring there are no actual technical difficulties when we start. Sorry about that. Hello and good evening, everybody. Um, it's now how fast? So we will get started. Sorry for those yet. Witness minus R D is technical, and I will call incompetence but poor technical ability earlier on. We're not very techie people. Hello and welcome to session three of the atrial healthcare Syrians. This is going to be an introduction to geriatrics. Pediatrics. Those who received the email that should be all of you will see that we're doing geriatrics. First rub in the originally advertised pediatrics purely because presented preference. So today, uh, we have the wonderful Saudia who you'll have met in last week's session. One of the physical physiotherapist We'll be doing our session on geriatrics. That's the point which probably correct me and tells me I got the wrong hospital. But I think that's the right hospital she works at. It's the right trust. Wrong hospital, Dammit! Your royal, not human. Come on. Okay, uh, that I think of spot pediatrics. Wrong. It's well, that might be because it's an American program. And the party is pediatrics with Josh, who is a firing a medical student who will have met the first week we doing these? Um, this is my This is about as techie as I can get. This is my text skill. We're currently on the third session of the five week Pediatrics and geriatrics. Uh, obviously, just those garments and Dad yet hopefully you're pretty aware of what's happened when, uh, if you have any queries, any point email may I think I also sent out a link for general feedback for our improvement. Said, please fill that out as well. If you have any ways, he wants to improve on with that. Sorry, I don't mean to take your load up your slides. Yep. Second Oh, that was so smooth. All right, I'll 100 Saudia. Thank you. Uh, so I'm going a bit on geriatrics. So you might hear is Jarrett bricks care of the elderly? Um, ps older person service. Lots of trusts Call it different. Lots of different things all to do with, like, the way it sounds in the way it looks and other people weigh other people interpret care of the elderly. Um, might hear it shortened like c o t e when you're looking online notes and things. So the aim off this session is Teo give you a brief entrance. What normal aging looks like to then know what some of the age related diseases and conditions could be in how you know. Well, it's just normal aging and what's actually a diagnosis, what we might have a test for in a healthcare setting. So I've got one of my am, So if she things that, um, we use in the current trust that I'm working in to assess any patients, Um, and it's heavily focused on elderly fall. Is that come into any any then a bit more about some patients into care and how we go about achieving that in older adults on a bit about what it is first. So with normal aging, you've got these different systems of the body that get affected. So with your cardiovascular system, your blood vessels start to get a bit stiffer, they lose their elasticity, and you're so your heart then has to work harder to keep up with that on. Because of that, you've got this risk of having a higher BP, also known as hypertension. I'm on D when older adults do activity versus see when we do activity. Our heart rate increases quite a lot, but you don't get that variability as you get older. So again, the heart has to work harder to pump blood around. Uh, bladder and bowel changes. So increased constipation just to do with the way got motility works on how things have passed through your intestines. People haven't increased urination frequency on more prone to UT eyes, uh, developing incontinence, which again to do with, um, muscle changes which will cover. And then when I get around to bones and muscles, people starting to have difficulty hearing higher frequencies. So a little bit of hearing loss, uh, with the vision difficulty focusing developing cataracts with an increased sensitivity to different or changing light levels. I'm sorry about the hearing. Sometimes all the people can find it quite difficult to follow a conversation in a crowded room. So with all the different frequencies that going on or the thank you go, you're watching the lips of one person. But hearing something different on that sort of mismatch can be quite difficult. Teo, sort of gauge and interpret versus how we end up to our age is currently with your bone muscles and joints. You've got a reducing bone density so people might, uh, developed osteoporosis. Uh, also you might have had that was closely called brittle bones. Increased risk of fractures because of there is on. But you've got a loss of strength, muscle endurance and flexibility on those three things all together. They affect your coordination, your movements, your stability in balance. So that's where you know things like appropriate walking aids come in if needed. Or if we start soon enough with a good sort of, um, no, no even exercise program or just a program of activity on men maintaining someone's function, you can prevent the need for I am needing walking. It's in, like to look with memory. Might find that I speak already get more forgetful of reduced ability to multi task. I just want to focus on one task a time. I remember some of these things because I'm gonna be Austin. You too, uh, come up with some ideas later that, you know, use the chat as an interrupted function that Freddy's gonna than voice back to me as to what you've written. Um, get TV's most asking some reactions. So you're given a piece of information you'll time to process. It might take a bit longer. Um, on things like word finding difficulty. So again, heading into the memory bank that comfortable these words little bit difficult or slower to sort through that memory bank to them, find what you're looking for. I still have a lot of teeth and skin together. You've got, like a receding gum lines, which can often make teeth of it weaker on their four people might require duchess instead, um, because they're more and then was a little prone to decay an infection with that receding gum line. Because you're getting closer to that sort of no beds and things. A dry mouth can be a medication side effect that a lot of old runners might be on. Um, again, how your muscles reducing flexibility. Your skin becomes less elastic. It things, and it's easily bruised, which is why you get skin tears very easily as you get older. It's to do with that loss of the fatty layer in the skin. Um, I lost my notes. You've got approximately 11 million people in the UK over the age of 65 they're smaller groups of populations in the eighties to nineties. But because people are living longer, there is an impact on our resources, and our healthcare resources is low. But so we need to look at how we can address this and help people to live a healthier longer. I you've also got things like social factors on day physical factors that I'll get into a little bit late. Run, Um, but older adults can also have altered psychology, especially with things like that. He is passing away on them being left behind. Um, worries about how their family my coat when they themselves possibly, uh, which can sometimes not just those factors. It could be lots of other things that can lead to depression in all the red dots. Loneliness with the social isolation, especially if they're pig possible, passed away. Um, on. Then you also got some nutritional concerns, so we go on to the next slide. Some of the age related conditions, um, can get diabetes is more common. Osteonecrosis is more common things like a B 12 deficiency and anemia. Um, we mentioned so as long as I said, you've had those thie better and bowel changes leading to your UTI on incontinence, your cardiovascular changes leading to your high BP you're burning. Muscle change is leading to the osteo porosis on golf. Litis People are more susceptible to catching the flu and symptoms of the flu as they get older. And I mentioned the other things. So how might, um, some of those memory symptoms that I mentioned? How can they be different to, say, a dementia diagnosis? So the symptoms related Teo Normal aging. They might affect someone, but they're able Teo. So if I find the answer, so, for example, if someone's I'm misplacing objects, they might be able to retrace that steps to find that object. Where is it? Someone with dementia. Okay. What? No, no. It's all where it could be. Or for example, they might not even know where they are, despite it being a familiar place. So you say they're in their own home, that they think that somewhere else, Uh, and again you might needs also want to repeat something. But it could be that you missed heard or you didn't quite process it or understand that the first time. But someone with diagnose dementia, my end up, asking for that same information repeatedly with sort of no end in sight. So you ask if you're asking, they're asking you 345 times in the same sort of conversation time, period. So the symptoms of having a more profound effect on someone's day to day living rather than just being an inconvenience, if that makes sense. So the British Geriatric Society, this is Ah, I haven't actually credited it, but this is a little info graphic from the British Geriatric Society on what the comprehensive geriatric assessment is, Um, ate something there so most any team members would use when assessing on older. I don't to put all these different aspects of their life together, uh, doctors, ones will obviously looks like different. Teo, what I might use is a physiotherapist. I'm going to actually change what screen I am sharing, if I can to show you the one that are used at work Currently. Nice busy buddies. Bunnies. Okay, I changed my whole screen. Oh, great. Okay. And, um, so I can just open this up. Does that show you? I'm seeing nothing. You see, in the Roman screen, Right, Hold on. There we go. Yes. Uh, no. Oh, one second, then. Okay. Yes. Oh, so this is That's gets quite long, but it's split into different sections. So we start with, you know, just gathering why someone's come into hospital. You might have similar assessments that community teams my even used to process when someone is coping at home or how they how they're doing when they called in to a clinic. Um, but this is what we use in the emergency department, so I'm gonna go for it. What sort of that? When I go through this template, I'm going to go through the idea that the patient I'm thinking about talking about is maybe an older adult who's fallen over and being brought into hospital. I'm often in the emergency department where, as physios start trying to decide if this passion is safe to send back home. Even if they've been cleared medically is it's still safe to satisfy them back home. Or are they likely just a bounce back into any, eh? So we want to get her a little bit of their sort of history, why they've come in taste in the hospital, what's on the investigations. The medical teams done on what the results of those were. So if they fell over and maybe you're querying that they fractured something that the X rays show whether there is a reason a fracture on, in that case, whether they can walk on, said fracture or said injury on the hospital history. So what else is that off note that could also be affecting what's going on? We'll start our documents with making sure that we've introduced our role in that we've got consent to meet the patient, sometimes an order I don't mind not be able to give consent, do two cognitive issues or if they've got dementia diagnosis. But concern is another whole topic that could be done at another time. Freddie know on noted, uh, but why was seeing someone? So we're seeing them in their best interest in that case. So we got a little bit of social history. So where they lived, do they live alone? They live with friends. That they live with. Family is just so that we know what support they might have when they go back home. Um, often, we might call that person or we'll call the next of kin to double check some of this information. Just in case you were worried that what the person's given us might know quite be corrected if we're thinking they have cognitive difficulties and cognitive issues. Uh, we care about what bars someone lives in the cause. Uh, it alters what social things we can refer to and recommend informal cash that we want to know. If the people that are living with this personal that's surrounding this person in their life, if they're providing extra support that, you know, maybe it's not known to medical teams. All the GP team also Shal services that, you know, friends and family have picked up this supporting this person because that's that's what you dearest friends and families. You want to help people, but actually, maybe it's getting to a point where, as you know, untrained professionals, they're starting to struggle on that. Actually, many things might need something called a package of care where they have care has come into the home to help a person. So that's what Patrick carries. Sometimes people come by by that privately, or it could be through social services. On this just stands for the number of times a day, once a day, twice a day, three times a day, four times a day. Get east of those sorts of, uh, so it's short hands. When you come into medicine for healthcare, what exactly the care helps with. So is it that the carriages prompts them to make an eat breakfast? Teo, get dressed, have a shower? Or is it that the care actually has to help the person to shower like they would? They wouldn't be able to shower if that person wasn't there to help them. Uh, if they're known any other team so that you can link him with them or make sure that this other team knows. Okay, they come back into hospital, something's know, quite going right with the community plan. Is there anything that needs to change to support them so they don't keep bouncing back into hospital? We asked about someone's home on go home environment so that we know what sort of level of mobility we need to get back to you, to you be able to get back home. So if they've got a set of stairs in their home, they need Teo climb to get to the bathroom. They need to be able to do that for us to discharge home. Or is there a way that we can discharge from home to live, maybe downstairs in the living room on set up a different toileting facilities in the meantime with some equipment? And is it that they could do the stairs if there was just some rails pertinent for them to climb the stairs? Um, those those sorts of things on it's like like, can they do those things safely? So it's one thing to be able to do them. It's another thing to be able to do them safely, which is where your physio assessment comes in. Yeah, so if you're another healthcare professional. Think about referring to a busier when you have another writer that comes in with a full. So we check how someone was reading about before they came into hospital. So did they. Did they walk with without any AIDS on? Now, for us to be for us to discharge, that will get him walking again with a. We need to have him walking with a with a frame. Then that's a change in function in my safe to send him home with the frame. But ideally, we want to look to see if we can aim to get him back to where they were, So we'd be looking at maybe referring them to a community physical therapist. I'm sorry that I'm talking very much from a physical perspective, that that's what I know. Um, we can help other people jump in or add some things like to run. Maybe from the cognition side, we often relying on the occupational therapist, those colleagues and I'm not more about cognition and memory. But we can do some quick screens to see if it would be a portrait, especially if there isn't already a diagnosis. Just check whether Maybe they reached the point of the diagnosis, or perhaps to refer them to someone called a memory clinic, which is usually an outpatient service. That GP is often refer to you when they've done a quick cognitive screen in their practices, things like domestic toss. So we want to know that this person can actually, you know, proper meal. So sometimes it's a simple is whether they can put something in the microwave and start the microwave, or whether it's it's nice to know if they were actually fully cooking in preparing from starting from scratch. To make a meal on again helps you to see that difference off what it was before they came in the hospital on where they're right now that we get on Teo, a full assessment usually really completed if the patient has had a full or we know that there are a risk of false because previous admissions have bean because of falls. Uh, there are many reasons once a month in full, it's not just, um so. Sometimes it can be simple was tripped over something, But again, we don't need to look at how often they're tripping, why they're dripping where they're tripping. Can we prevent it? Are they falling over because they're feeling dizzy before they fall? That's an important question to ask if someone gets dizziness. Um, cottons. We wanted our way, maybe falling over at nighttime because they need to rush to get to the toilet in the middle of the night. Um, all they sort of falling. Are you, uh, or passing out when they go to the bathroom? That's a little medical thing that can happen, Uh, often happens to men they can pass out when urinating. Um, can happen, told immense. That's another thing to try and pick up. When is it happening? And where is it happening? If they have fallen, can they get back up? Or do they need someone to come in a system, or do they need an ambulance to come and pick them up? Um, usually someone already fallen before the sorts of things would have been done, and hopefully things like a pendant alarm would have been put in place. And that's Ah, it's a little button that people come where either one they raced around the neck that leads to their telephone line in their house. And when they fall it over, they compress it and they can talk to someone who can then alert their next of kin or the ambulance service. So this is another NBT thing. Are they more than four minutes? Because off the medication can either interact with one another, have side effects. Or you could have your main medication, another medication, that side effect, and you put them all together and you end up but someone who's feeling dizzy or it's exactly grated the low BP. Or it means that they have an extra drop in the BP when they come to stand up. Um, well, they have that they were getting the medication for that, and it's something the other way. All. They had five drop pressure, and they give you medication to lower it. I'm not feeling dizzy when they stand up, so that would take that often. And in some trust, you have, like a priority team on the consult in that frailty team will scrutinize all the medications that they're on or along with the pharmacist, is while to make to see. Can we get this patient off of any of these medications? Is there a medication that can do all these things at once just to see if we can improve someone's quality of life. Uh, the vision and hearing. So do they wear glasses? Is that prescription up to date? Uh, is it are they falling over because they can't see where they're going? Are they falling over because they're not there? Put me. Their hearing is impaired to the hearing inspector morning than the other, and it's making them off balance. We've got an environmental assessment on. So before my current job in this trust, I was working in a community false team, and they go around to people's houses to assess them in their house on I would always be scanning the house, making sure you know what sort of trip houses they have. Do they have a lot of loose rugs? Do they have the steps between their rooms where maybe we might want to put a grabber, offer someone to hold on to you before they take those steps? Those sorts of things. We then have the ankle. High dog. Yes, it's always the one. Yeah, I've had a lot of patients that trip over their dog. Yeah, I can't exactly help you with that one. I can try and maybe improve your balance so you don't fall. When the dog runs into you. It's a bit difficult. And then we often try to ask the patient if they have any worries about going home. Um, if the next candle carrots have any worries about the patient coming back, you know all those two parties working well together. Are they coping the old? The patient themselves might feel that their coping, but actually the carries doing so much work with the care is getting care if it's big on. Actually, he's in coping very well and would like some kind of rest by How can we go about facilitating that? Then we have objective assessments on a little sort of outcome, measures that we can do. This just allows us to have a bit of more of an objective school so that we can compare things in the future, especially if we then put in, say, an exercise program intervention. How things got better have we actually reduce their risk of falling. Um, so when we see the patient, we'll go three. Some of that like again do they understand why they're here. Then we'll look at their strength, the sensation. And then these are just two little cognitive screen. So we'll just pick one or the other. Often, therapists have a preference or trust several preference as to which is used, that they're very common. You can google them and have a look at them, and then we'll check. Exactly. Wait, wait, wait, wait, wait, wait. Those are on your assessment form. Yeah. I'm not gonna sitting here. Going through them ready? No, no, no. I was going to say it. My union. We've been made to memorize thumb. Oh, that's still a story upset. That's a bit silly. I just make yourself a little memory card for when you're actually in the hospital. Just memorizing for your exam. Eso the current level of function. So we found out what they were like before we know. Going to see this patient. Can they get out of bed? Simple. Is that sometimes, um, people couldn't People can really struggle with, and then we have to start from that basically level of rolling around in bed, lying to sitting up in the bed, staring in the legs off the birth, sitting on the edge of the got the balance to stay sitting on the edge. And then we start to look at how they got the muscle power to stand up. Okay, they do. Let's stand them up and see what happens on. This is a very kind of busy, specific kind of thing. Um, and then we'll see how they get around. Um, sometimes people might walk to the chair. Sometimes they might not be able to walk that they can stand and sort of shuffle on the spot to then sit down in a chair. We want to know if they were also going outdoors and how their mobility is outdoors, how they were getting around in the community. So do they drive? Do they take public transport, or do they rely on friends and families? Drive him around? Um, how that personal carries currently? So do we think so? Sometimes we'll just have a chat with the nursing staff, or we might actually do this as an assessment. Usually it's ah, it's an ot tasks to do these assessments, but often, if a patient needs the toilet anyway, then you just take him walking to the toilet, see what they can do for themselves. They get a bit stuck or whatever. You can always get some extra hands in to help, Um, but if they get stuck on the toilet, then you know they're not safe to go home, because if they try to go to the toilet on their own, they get stuck there and they might fall off. That's a little red flag to go off to, say, this patient not safe to go home. Um, if someone say you tell them Teo, stay in that channel. We need to cool about school for another, but they don't do that, and they constantly try to get up again. That's a risk, because even if you've got care is going into their home four times a day, which is the maximum in most social care services, is four times a day. So that's four calls, maybe up to a maximum of 45 minutes to an hour each. I'm not only in the daytime from say something like between six AM and eight PM between those times, what is this passing in to do? They're going to try and get up and walk themselves, even though it's very unsafe. They might feel like her. So we need to We need to work out and make sure it in their best interests and safest for them to go home. Well, do we need to maybe have a discussion with for the patient, the next of kin Onda? Who else is whoever else is involved in this patient care. So the whole NBT but that maybe they're not safe. Go home. And maybe we need to look at something in the interim like something called a step down bed. So it's a bit like a nursing home placement, but without the long time affect, it still continues. Assessment on on. Then we just got some objective measurements that we do to be able to then see how the past is doing what we can talk, get our treatment too. So that's a bit of the geriatric assessment that we use is a physio similar stuff in other trusts. But I couldn't find my favorite one. So I'm going with this one. Uh, right. How do I change your screen book? But while Saudis changing screen that's full or elements they're off that quite common for any sort of aging care, whatever specialty you're in there. A couple of interesting questions here. Don't know when you want questions side. If we do them at the end, I just have a quick glance of them you've got, Uh, yeah, um, some of these points, we're actually going to come up, so let's leave her city and right, so you don't realize it took a long time on that. So what is patient centered cat? So this is about keeping your patient for the person that's in front of you at the center of their own healthcare. So we're not talking about Is this in this person's best interests? The patient offering can tell you what they want from what they need on when they call. They might have family members around that can tell you what this person, months of wanted don't need it. Um, so this is this one's got the credit on the bottom? Uh, just a little info. Graphics. Again, I found online about different expects a patient centered camp on. We want to make sure that if we're doing something, it's what the patient would work or once. So things like if there's a family member visiting the patient asking what the name is. Checking the patient, happy for you to have them involved and finding out what the relationship is. So, you know, with a friend family partner on making sure that once the patient's told you, you keep using that If the patient's told you they don't, um, had a patient last weekend who I was offering water on. Everyone else was offering her water, but she wasn't really drinking it on to me. She finally told me. I don't really like run a temperature or cold water. I prefer hot water. So that straight way I heard that that over to the nurses, they went on their their little chart to make sure that that's what she prefers. I went off and I go out. Um, it's off a warm a beaker of water for her toe. Have to drink from started drinking a lot of water, those sorts of things. What does the patient want? What makes them comfortable? What makes them feel more human? Um, if there's a choice in that cat, give them that choice. If they could make that choice themselves or East involved the family in that discussion, then So I've included the biopsychosocial marvelous Well, because that's very important patient centered care. You would have seen this last week with the psychology talk part of the MBT. So it's about what makes you you and you've got these three different aspects to someone's life, the biological part. So what's actually going on with their physical health? Medical health? Um, how the sort of functioning in life. Then you've got a social asset. So you've got the friends and family, the loved ones, the partners, what they're sort of social standing is go back to think about. So is this person someone who would maybe go to the Bridge Club every every week, every other day? Um, and that's where they feel sort of most of hope. Is there a way that we can facilitate that happening again? These are sort of things you need to tease out of your patient just by talking to you. So you're finding out what they like, what they want, what they used to do. Would they like to continue doing that? Okay. How come we first did it Take that on then? Someone psychological expect So what? Their personalities like what they're sort of beliefs and attitudes are s. So they chose to completion attitudes to anything in life, not just things like religion or political affiliations. Just could be the attitude Teo aging for their acted you to dying. Often it gets me sound. People on asked, you know, where would you like to die when the time comes? Would you like to be at home surrounded by your family and just made constable? Or would you prefer to be in hospital? Having every procedure under the sun is try and stop you from dying. Sometimes they get according where medically it's not feasible on it become it can be sort of almost too much. And you're medicalizing death where his death is Actually a very natural course is this but happens to everyone. And it has happened for thousands of years since the beginning of humankind. Um, so they're sort of conversations offer Don't happen. Sometimes conversations about someone, sexual orientation. Those don't happen in your older adults. People think it's to be to ask about that, but actually they're still human. They still have the same needs and wants and, um that we all have. So ask someone or on. If you If you see that they're getting uncomfortable, they're fun. Back off. Um, but just show genuine interest in your patient because that can tell you so much about what goals you might want to set together. Eso the patients go might be, um, Teo be able to play the football with their grandkids. Okay, at the moment they walk with a free. But is there a way that maybe we can facilitate so kicking of a ball practice while seated in a chair, making it safe, but allowing them to engage with their grandkids in that sport? Those sorts of things on addressing someone's emotions is, Well, there are a lot of community things you could refer someone on, too Enough about that. So challenges communication on cat. So this Freddie is where I want you to try and feed back to me. People might come up with, had a lawyer. Oh, that's what wanted. Um, So if I ask you what? From some of the things that we've spoken about normal aging, what's what challenges do you think can come along when you're trying to communicate or care for school and older adult, Anyone with answers please just put it as a question, and I will consider it as a chat. What one day left lung cancer in her of people being on David's answer. Um, that was a couple of questions. Uh, one question for you. Sorry. Actually, at this point, does it take a long time to go through this entire form with the patient? And what if they get bored or frustrated? Because of all the questions so often in a me will try and do the whole form or much of the forms we can, um often will leave, maybe get the social part from the next of kin so that it's taken out of having cognitively overload the patient sometimes interesting to know what the patient thinks in comparative what someone else's set. Um, if the patients on a ward and we know they're gonna be staying for a little longer, will will definitely break it up. So it's not too fatigued them and to get the best out of the patient every time. But in any things were a lot faster and often because they're medically fit for discharge. And then they're just waiting on physio to see too clear them off. Um, that could be some time pressures, but actually, you want to make sure this patient is safe, so it takes you a long as it takes you to make that decision on. If you're uncertain, then we're going to say this patient is not safe for destruction. It's always gonna be safer to maybe keep me in for an extra day and complete the rest of the assessment the next day. Or find out the rest of the information that you need often or someone already has a package of cat we can. It needs an increase that can be easier to do than starting a new package of care. But there are. There are things that can be done to make that part quicker. A swell but specific assessment wise. When you get a lot of practice at it, you can do it a lot quicker. So some of the motor parts on the sensory parts I'm I might sort of look like I've skipped them, but actually I've done them in what we call in function. So I've done them while So I've got the patient to do something else. I've in my head ticked off that, actually, Okay, They sensed this or they knew. Well, um, what this sensory input waas in that part. Motor wise, if I can see them sort of just getting to be a quick thing of, like, razor on impact. Um, lift your legs impact. So I know that they have what's called anti gravity muscle movements. So I know they have enough muscle movement to be able to stand up. Walk. Uh, so then I'll just get them straight out and start walking them. So then I'm looking at some of the higher level things rather than focusing on each muscle strength what's there in the bed and then giving them out and then walking them so you can speed it up a hell of a lot. Of course, um, answers for you. So you're just quickly reiterate the question so that it's all in connection yet so challenges that, um, charges and how they might affect cat. Especially maybe with regards to communication when dealing with all the patients. So we've got hearing and comprehension slash retention off information. Stubbornness. Yes. I won't lie. That's more common than you think it would be. I would agree. Fear Yeah. When people are not fluent in English. Really good. One side here and I both work in London. So that's that's far more common where we are, then. A lot of parts of the country, but yes. Yep. Someone has an impairment that leads them to not to be able to communicate e g brokers a phase here. Love it. Currently working stroke so we can see a lot of that yet look different impairments leading to communication difficulties. Yeah, And then you've got patients and understanding. What do you take? What you are telling them all Having difficulties with hearing? Yeah, wording or phrases or sentences that might lead to confusion. And quite a big one on the end here if there are unconscious or in a coma. Yes. Um, close to related Teo elderly patients. That can be your most of your righty. You patients? Actually, which again? We always talk to them before we do anything to them. I just saw one more come in yet. And that's if they have dementia. Yeah, free. Understand? And if a patient has different preferences to their kid or which of a member of family is looking after them Yeah. So, uh, that one. So I just came up with some random ideas. I put down the slide, but actually, a lot of you've got some of those in some even better ones. Actually, um, I'm trapped in use of dentures. A lot of the time I found that patients come to hospital, and then they don't have dentures with them, and then they struggle to eat, managed to lose the dentures the second I actually cast off knowing how to clean dentures. That's something that I've I'm I have to learn how to do it. Uh, it's like I have no idea how to clean. Dangerous. Okay. Right. Let's let, um, patients can have embarrassment about even just the normal part of aging. Like the incontinence. Um, patients could be quite embarrassed. That was not supposed to happen. Um, information on overload. I think that was woman came out maybe more under the cognitive side. So if that understanding what you've given them do they understand that in the format that you've given them, if you've given them a sheet of paper to take away, can they actually read it? Can they see it coming? Process worked in information, or do they need a different form? For example, the slide that I have just created? Um, it's no actually very accessible. People are visual difficulties, like her problems with the different backgrounds, like I'm actually struggling to read what I've put on the yellow that ground. I know I put that vision, depression and mood changes, but I struggle to read it memory. So if someone's remembering what you've told them, for example, used to call about. But they forget that, and they just want to get up and fall over overcoming some of these. We've got different methods of communication, as I was suggesting what's worked before. So if someone's had a house, a longstanding issue. So maybe the dementia was diagnosed many years ago, and people have come up with strategies to communicate with this patient. Obviously, dementia can progress, but what's worked before can we get that back to this situation right now? What's meaningful to the patient again, coming back to patient centered care, The format just mentioned that can friends and family help? They know the patient much better, or we hope that they know that much better and can help us in this. Do we need to make other care? Stuff wears to do. We need to make a referral to the occupational therapist. Do we need to make a referral to podiatry? That's quite an important one that I've missed out on. You should have seen on that falls assessment. Do they all they able to tend to that foot Can't. Well, do they have helped to do that, or will they required community podiatry because of your foot? Helps not. Good. You're not gonna be walking properly. Um, okay, right now, actually managed to finishing good time because now we have a summer normal aging versus diagnosable conditions. I hope that that's well I managed to cover on challenges to providing care in this population. What we is healthcare professionals, candy or you guys, is future health care professionals. Remember what I've gone through on this isn't exhaustive. There's a whole lot more out there. That's why it's a whole specialty on its own. Well, like my current streak consultant is also the Jerries consultant because once upon a time, stroke was only considered a problem off the elderly. However, I have many patients who are not over 65 so care of the elderly is classes over 65 in some trust. Sometimes it's pastor's over 75 depending on how stretched their services. Really? So the previous trust I worked up, um, and any I would see over 65 on the file to team would see the over 75 that were a bit more complex. If that makes any sense on then on questions, Thank you for listening to me is one I don't know if that was good. Yeah, I think you covered quite a lot of really interesting stuff in there. I think it's quite intense. The first time you ever come across one of those assessment forms is very scary. Normally. Now, the first time you're the one made to do it seems scarier. But unfortunately, a lot of health care comes down to these sorts of things, and a lot of it comes down to make sure your patient safe. Um, going through questions were answered. The majority, I think, uh, all these age related problems can make a patient feel very helpless and like a burden, which I assume is a feeling they hate. What steps do you and your colleagues take to help them not feel that away. Sure. So I'm gonna heart one about this, but that goes back to your patient centered care in uni. That's actually one of the lectures we get on one of our site modules, which wasn't actually that useful. But there was one lecture that was related on health related psychology, which was actually useful on. We covered some of this about how, as people age, they can start to feel helpless on this burden off disease that they can feel. What do we do? We just try to make them feel like normal human beings. Reassure them that it's okay. Your patient has soil themselves. They're embarrassed. They're upset. You tell them this is okay. This is normal. It is my job to help you on. Do you make it? You try and make it as painless. Process is possible. If they want you to, like awesome. Do you want me to tell you exactly what I'm doing? What? You are just going on with that and maybe clean. I'm sometimes for the sake of communicating with someone who maybe is unresponsive or in a coma would probably tell them everything that we're doing because we know that they can hear on. They can't exactly express that. They didn't want to know what we were doing, and it's sort of a bit more kind of and gives them a bit of preparation. But with someone who does know, I can communicate back with us, ask them what they want. How do they How are they? Well, that we spoke to them on Treat that Often you might find that people raise their voice and they're talking to another person, even though they're human. Might be intact. Well, that hearing aids make it so that they can hear you perfectly. Always, you have the ones where you might need to shout in that year, all right, things down. Or they've lost their hearing aids on the ward or someone's lost the batteries. But again, it's that patient scented talk to them. What do they want? What do they need? Yeah, I think that there's a lot of different things in place, depending away. You work as well, So some patients have a little board which has that their information about them, some patients, particularly with dementia. Um, I have a little book which tells you things about them that helps the people looking after him on that. That shift here quick, look through the book. It will tell you things about this patient's life. So then, when they start getting confused, you might be able to draw lines between what their behavior is on what they're trying to communicate. There's a lot of things out there. There's no hard and fast rules. It's it's what works in that situation on what you conducive. There's another question that something similar and I mentioned the idea of good clinician versus bad clinician. It's ultimately good, Good clinician, Whatever specialty, urine, physio and that's in nursing the list goes on and on on the good clinician is the one who takes the time to know what the patient wants and to try and help them and make them comfortable. The bad clinician doesn't care and just does what they're going to do and just ignores what what the patients needs. All yeah, exactly. There's no point in. So I was talking about holes. There's no queen in saying so, Michael, It's for this patient. Teo, be able Teo, um, walk 100 m, but actually all they want to be able to do is Teo stand for long enough? Teo took their meal like those goals they don't they don't match. So I love this personable contributors. They just want to be able to stand. So there are things that might not make sense to the patient when you're sort of doing the activity. But you can always explain, Well, we're working towards your goal, your gold standard. This is going to help with that on different can get them to that than perfect. If we get into my goal of 4100 m, then we've exceeded that. But actually, if that's what they wanted to do, I don't need to force that goal on them. So there's also one here about sign language. So do you use do you learn sign language to communicate to, uh, I think really the also. That one is that elderly patients with hearing loss struggle to learn what struggled to speak English sometimes speak their main language. Learning a new language of that point is incredibly difficult. And I would say Night on Impossible, Um, but for example, I sign, but I've never found a care of the elderly patients that I can sign with aside a lot more working doing with pediatric stuff on? Yeah, probably. Pediatrics. The main place that ever comes up. Um, yeah, so I think sign. It's a nice idea, but the problem of the time, it's just the patient has to be able to sign back or be able to understand what you're saying with it. Yeah, yeah, And also, even if you take it off the care of the ugly situation, there's a lot of death people that they use British sign language. They might need a different sign language, or they might opt not to use a sign language it'll that they communicate violet breathing. So again, how does your patient communicate on sign? I'm using Useful things have, but I got actually had a patient where I tried to use. Maybe it's a level one. Yes, I feel that as well also is actually learning silent, which is quite difficult specifically for a medical setting because medical sign language is not quite complex. Um, competitive. Yeah, I could be a cell over one. I imagine you probably haven't covered much medical, No, no medical lingo. It's a five. I think you covered be a PSA level medical language. Really? Yeah. I've done a level three. Okay. All right. Um, yes. So, yeah, it's a sign. Enormous. Another similar things like that. Like only patients losing their eyesight, Probably on girl learned Braille because this just takes so much effort for them to learn the skills that you know, they probably don't have the ability to put in. Um, yeah. Uh, then we'll fit. Use. This is the final one. Although I'm not quite sure. The question Could you tell us the name of the book about patients with dementia? Please? No idea. There were many on their quite a few out there. I might just take this moment if I can steal this screen chef or second, uh, which one do I want? Which one do you want that one shirt? Because it came up something that I should really recommend. Anyone wanted to get Healthcare? Is this the Dementia Friends program? It's a free online training. Better help you understand dementia and understand patients with dementia. There are no commitments from it. It's basically it's a miss that everyone understands a bit more about dementia from the training So then, if you come across someone with it in life, you may be doing a better job helping helping them in the world. I'll send out a link to the dementia friends website with the feedback link later, but I would really recommend this. Anyone wanting to go to health care, certainly for my but what I want. Healthcare assistant. We were made to your dementia friends. Training now was a medical student with been made to do it again. It's a good little package course on GEUN. Anyone who's looking to apply for a healthcare course, it's one of those things. If you've done this, it really does. It's another sort of not necessarily taking your, um no, no. So, like a tick in the box. But it's another thing that makes you look like a very well rounded and devoted candidate, someone who's interested in healthcare and want to do the best. They were very best they can, so I'd recommend it for people. Um, but with that, I think, if should we go for a five minute break before Josh, if anyone's got any last questions, please feel free to send them for Saadia of was What we'll do is Ah, wait until half past 34 minutes to run, to stretch their legs, get drink or anything like that, and we'll get on with Josh's session. So thank you, Saudia, Freddie. If people still around, I'm just out of it to to send the questions and plus for the sake of the recording, sure good. I think that was two questions on How do you deal with the situation where a patient with an age related condition, for example, dementia, panics when told to take pills? Do you also account so many patients who forget to refuse to take that prescribed medication? How do you manage the situation? So I think you answered that one very well with, like the doctor boxes and pill reminders on. Sometimes I'm going to be given, like electric ones that dispense the pills the court time so that they know overdosing. That's very expensive, but in certain conditions they can be provided or families compactors and privately on with patients panicking or refusing. It's a very tricky one, so if you can call the patient down and get them on your side and take those pills and that's the best scenario off, and then you end up in a bit of, ah, a legal situation where you end up with sort of things like best interest meetings and making best legal best in first decisions whereby in some care homes, nursing homes really not care homes nursing home because the nurse needs Teo administer some of these medications, but it can be done in a way that's called that it's covert. So medications given with people's food. But again that has to be properly legally documented. To say that this is what we're doing for this patient on it is the least restrictive method on it's in their best interest or one. You take away that patient getting agitated and panicking every time, but you're also giving them a medication. That is probably uh huh, life saving or life enhancing. It would be one of those medications, probably probably not something like, uh, a victim in supplement, but the very important stuff. They'll do that for potentially. That was my question. Thank you for nothing. That's quite good. There's have never 30 seconds issue, and Josh, you can kick off eso it is half past now. I think good time to make beginning. So hopefully enjoyed that talk on geriatrics. We're gonna go and go to the other end of the spectrum to pediatrics now kind of one of my favorite topics and hopefully will be little bit more lighthearted than kind of old people in hospital. But we'll say yes, the money's draft. I am a final year medical student. Imperial Um Onda. Yes, We're going to talk about about pediatrics on D. Based on kind of some feedback, I've made this really quite interactive. Hopefully eso if everyone could go onto this length so poly vi dot com for such Josh age one. I want a stick it in the trap. Well, maybe some questions and interactive bets for you to kind of, uh can look up. Um, they stick in the job if everyone would like to look into that. And then whenever you see this logo, um, the Poly VI logo, that means there's something on that slightest related to a Poly VI question. So hopefully we kind of remember them all. So go on, associate. The main things I want you to get from this presentation is like how to assess and examine a kid being able to spot some kind of the key presentations impedes on, then a brief overview of pediatric resuscitation because that's always useful to have so start for the case. So you are first aid. Is that county fair? You got just He's a four year old girl. He has been brought into your treatment center by her mom. She's not herself and hasn't in for the last few hours. How would you like to approach this patient festival holding one? So how would you rate the knowledge of pediatrics? First, let's see what people are people of sides that generally pretty good. Maybe in the middle. Um, some people not so good. Go. Okay, So if you go onto the approach question, what is your approach? I guess we have some comedians. We've got a doctor, A B C. It's always a good stop. Where's your mom? Brought in by ama. But yeah, I guess it's a good question. If you came in the room. That's, uh, after a bit more information. Is anything unusual happened while they've been there? What the symptoms? What does not herself mean? That's a really good question. They're coming. Coming within the vein. You want to know what they actually mean by that, Like more even answer talks in both in June. Gauge moment. Build dressed the drug. Good thing. Excuse yourself. Talk to the patient of months. That's actually really good thing for Pete's. They like if you actually talk to the kids, not just kind of over them and ask them, um, what she means exactly as yourself. Doctor C A, B C D E. If you expand it a little bit good, that's the parent. What's changed? What she's not. It's opiate here. I see. If the body pain have a good one on what she normally like course, we'll move on from there. It's so, um, your approach. Do a couple things. Really. You could take some observations. You could take a history. You do an examination. You could call 999. Maybe you could get the bubbles out and see if you can kind of distract her. That there's something more simple we can do with this on gradually, a couple of videos, Hopefully they'll work. The audio might not work, but you never necessarily need audio for this Onda, Just take a note of what the kids, like in these videos has the fast one little carries. Their thrush may be the younger kids that were gonna common above 81. Um, and then I take a look in the ears so years could be a particularly challenging piece off the exam, so we need to order. Still did sort of neck defeat that you, the whole GI Ent exam Eyes, nose, throat. And then here there is and I've got two more videos here. These are both kind of quite sick Children. This is the first one, and here's the second one. So if we go back to the Paul even bought some differences between these kids, it's if you can't think of any differences, tell me which ones you think a while of which ones you think are sick. Uh, age. That's true. Um, yeah. The older kids in the first one is much more aware of what was going on. Breathing difficulty. A definite could save. The other two are having breathing difficulties. Person's definitely wake a much more responsive and good breathing seesaw breathing a noise in the second get. Yep, the baby is sick. I would agree difference and responsiveness Absolutely. First is interacting engaging? Yep. On kid was a lot of responsive, Uh, breathing. Yep. The breathing is definitely different. First drug is okay. The second one was quiet and not breathing properly yet. My great. I'm gonna look in the movement yet. So Cherry sitting up with this struck that would be struggling to breathe. So these are things I came up. So the first count, Normal tone. They're holding himself up right there interacting. They're looking around the communicating. There are good things. They got normal breathing sounds. They're not kind of increasing their work of breathing. It'll they've got normal positioning, their color and the world refused. Then if you look at the baby, they're not. You're really using the limbs and I'm reading the bottle. They're not really interacting with their environment. I'm not crying on it. A baby's not crying. It's generally about sign on, but really working hard to breathe. You can see the retractions in between their ribs on. They look quite flushed. If you can pull up to the third kid. The skin was looked very sick. If you just kind of looked at this kid, you would go. Actually, that skin is really sick. They're pale. They're not interrupting there. Basically response. I'm responsive. They've got this weird breathing thing going on where they just It's going one way in the autumn. It's going other way. They're really strict restricting to breathe in. You can hear Strider, which is like an airway sound, meaning that airways potentially obstructed somehow and they're pale. So all of these things that you think actually the first kit is really quite well on the other kids are quite sick. He's been to a pediatric assessment trying, which actually someone record talked about on this is This should be your first thing you do when you're set skids on. The first thing in the assessment triangle is actually just a look at them. So look, their appearance, what they look like. And you remember kind of the things you need to spot in this by the acronym tickles. So what's their tone like? Are they fighting you or are they floppy? How are they interacting again? Are they fighting you or are they? Don't really care that you're there are they could dishonorable. So if mom picks them up, do they stop crying or do they start screaming more, you can see how they're looking. You. Are they looking around the room with a interested in what's happening, or are they just kind of staring off into space on do again, the speech or they cry. So do they sound like they're speaking normally? Or are they crying normally or tastes really screaming or they're not crying it all? The second part is working, breathing, So how hard of a breathing you can listen for airway sounds. So when you breathe I/O, um, you can look at how the positioning So kids were struggling to breathe, and even adults as well they'll do cynical tripoding. Where they sit up on to try to open up the rib cage is much, much as possible. You can see retractions. You can see them under the ribs between the ribs on top of the ribs, which again indicates that they're using. They're ripped muscles to breathe when they really shouldn't be on, but they might have been flaring the nostrils a swell, which is often kind of very subtle sign. But it's just that that they're really trying hard to breathe and then circulation. So basically What is the skin that like? I'm a pale of a mottled? I think that that's kind of like a kind of like a perfectly appearance with lots of lines on the skin. You'll see they sign it. So I've got blue in part for probably their lips or their fingers on or are they flushed? Kind of the opposite on all of these things together can give you a very good idea and not a lot of time at all, whether this gets sick or the skin is not sick on down much time, really, you have to play around before you need to do anything about this. So about to break your question, I get that go. How would you assess in the neurological function off a two year old? We'll go back to the Poly VI here. Be as yeah, yeah, be as creativity can, or clinical as you can jump. Yeah, definitely on. By the way, this is a one word thing. So if you put multiple words that I like, put them as such but run, that's also a good one. You can see how their legs working, actually, how their balance working draw a circle. Yes. So you could look at that coordination and how their hands are working. Laugh, tickle? Um, yeah, I guess that's maybe tickle them and see if they left a hammer reflex on the knee. Um, sing. See the interacts reflexes? Uh, yes. There's later communicate. Stuff like that will stop there. Just it's it's been like that one. Um, so if I show you this video, we'll watch the city, and then we'll go back to the pole. It's I like more bubble. Yeah. What can you tell me about the neurological function of that child? Bubbles? Yeah. Yep. She's mobile running around. Uh, today's confuse. I would say so. Just kids. Kind of enjoying what's going on. Yeah. So normal urological function. Actively interested in the bubbles engaging? Well, kind of. Yeah. So she stopped by the hedge. Notice those in danger, such as aware of surroundings. That's very good. Um, able to respond? Yeah, on vocal yet so that loads of things there developed to come to the age eventually. Yet we haven't assess that formally, but maybe see, yeah. So actually, urological function is really good, and we've done it, looked at her, and he's singing. He's aware of the surroundings she's running. Should I get these bubbles with urologically? She's probably quite normal. So I've adopted. There's a video called The Three Minute Basic Chart Assessment, which is on a website for Like, said thinks with spotting the city care doesn't think that's really good. If you can sign up to that, have adopted it for essentially everyone to be able to use without any kind of extra skills of how to assess a kid in three minutes. Ready? So, first of all, look at the assessment triangles. So what's their parents? What's their behavior? Breathing? What's the circulation, then, in terms of airway to talk to the child, see if they can talk back. You can ask their name or the name of it breathing. You can count the respirator. You look for work of breathing. You can listen for airway noise is in terms of circulation. Check the temperature of the peripheries, the hands hot, warm or cold. Um, check their capillary refill times to squeeze on the nail and see if the color comes back and also do that. Maybe on the chest is well, and you can measure the heart right disability. So can they move their arms or legs? Coming Full facial expressions on D E. So I have a really good luck for rashes and have a feel of the tummy. Uh, realistically, that's all you do transect. It s that's a child. You can pick up a lot of things that are really wrong there on on. There's a much more kind of systematic way of going through this. If you want to call the nice traffic light, which is available online as well, if you just google nice traffic, like the fever in under five or something, which helps you determine whether the features that you pick up on this exam are normal, whether there may be a little bit worrying or whether they're very wearing it completely. So you've got things like What's the color of their skin, lips or tongue? What's your activity like, What's that breathing like, What's the circulation like and then other things as well. Um, but you can find online, and it's really good to the gut to go back to the case if we look at this kid. So if you think the appearance so kind of pale, Um she is on to the parents of saying she's pale, but you're not really sure she's got. She's not really responding to normal social cues. She's not really smiling on, but he's definitely got doing less than she normally would. She's got a little bit difficulty breathing and heart rate's a little bit on, but yeah, so we think is maybe an Amber in this. So going back to the case. So basically, she's being unwell for last few hours. She's not going. This is a sample history, by the way. So it's not the signs and symptoms. Allergies, medications, plus medical history, Last incidence on day event history or anything else is what we use in Saint John to kind of take a full history. It's good to remember, so 10% is, um, she's been unwell for the last few hours, but no allergies. Got no medication. She's not got no president of a history. She has some cake. A few hours ago, some juice, but she was okay if before he came to the event and then her observations of there. And if we go to the, um, Paul leave again, hopefully you should be able to see the table. And you can tell me what is abnormal about these observations. You could choose any of them. You could tell me whether things are too high or low. Yep. So fever Definitely high temperature. Yet yet the respirator, heart rate and the temperature? A lot more. Ah, high heart rate. Yeah. Yet respirator. Heart rate temperature. So you've got those on the rest of high SATs? Actually, that's normal, but high respirator yet great hearts. I never ridged respirator. Higher temperatures quite yet. Heart rate is very low. Yeah, there's lots of things there. Um, yet picked those up. Arrest. Great is but high. Or is that high in terms of high? So what else do we want to know about this patient? Can you think of any questions you'd like to ask? It's projects for a bit of delay. I think it's because there's a little bit of delay with teams. So when you're switching between platforms, there's like a little bit of a delay. Does it sting when you were potentially a very specific question, but it would help with one of the main causes of fever. Yeah. Then you form your friends, but, um Oh, that's a really, really good question. Especially if they're kind of people at nursery. Been on well as well. Um, gets kids gap. Viral infections all the time. Stress? Not sure. Stress, massively effects of four year old. Um, how does he feel? He is old enough to want to. Yep. Medical history. You've got blockages in your medical history. Um, ask the patient, You know, How do you feel? Have they got a pain? Yep. Travel history Money. Good. Yeah, I have been anywhere. They got cough? Yep. Headache. Again. Very specific questions. Customer history. Got that? We said, uh, she doesn't have any possible history. Has it ever happened before? Also, really. Good question on. Because cancers are if it's been, it has happened before and it's This is pretty much the same. It's probably the same thing family history. Yet if you tired here, looks good things. That I mean, uh huh. I came out with a few things. So is she needing to eat and drink is a good one. So she's not drinking as much Ondas a result. She's not winning as much. We've asked if if she if it stings when she weighs but she is she willing as much. Um, I give you a neither how sick she is, based on whether she's going well hydrated, dehydrated and what the bottles like. Um, so that kind of normal. Any vaccinations? There are two dates on Who is she with month? That's more of a safeguarding point. Just a kid knows who is if the pear. If the adult there says mom on. But it says them, Um, Andi, the kid says they don't know them. That's potentially a massive problem. Later on, she becomes more more unwell. We spot a couple of rashes on her leg. What can you tell me about at these rashes on there? Any questions you'd ask about the rash? Leptospira Sure. I mean, I'm not entirely sure where you're getting that from, but I guess it is a potential I don't know if it causes a rough like that. Yeah. So did she have any skin conditions? Do they blanch? Brilliant question, Um, asking us. And she also really good question. Yeah, it's red. Is it itching? A good question. Eyes painful. Also. Good. Uh, how long's it been there? Great. Uh, hives patches come into contact with anything yet, but also works and things like new shampoos on new shower gels off. People get allergies to those. Any allergies? Yep. Does it cause any pain for that? Single it? Yep. Great questions is that anaphylaxis doesn't massively like anaphylaxis in the moment. Um, telephone set. What? Led up to the answer If she's noticed it before. Yeah, All really good. Uh, what first of pair is it disappear in a plan? When I got scripts pressed against it? Yeah. Great. So is it blanching? So people talk about the glass test is they did that as a way of kind of telling if, uh, sh is blanking on up. Which isn't, she means, Does this rash she's got here? Does it This one? Does it go white or disappear when you put a glass over? Think last test isn't the most reliable test in the world. What's actually better if you just stretch the skin with your thumb? That works a lot better than glass, but yeah, if it's nonblanching that suggests that it's meningitis or it's meningococcal septicemia until basically proven otherwise, she's sick. If you've got a rash, that's nonblanching. We're going to be worried about meningitis. So this is an infection or inflammation of the meninges, which are the kind of membranes that surround your brain. It's caused by quite a few things, so generally viruses and bacteria. But it come because by a few funky other things, like TB and funguses, and not some weird things like that on get presents in lots of different ways. So this sign from military shows thumb all, really, and they're generally quite standard. So fever and a baby refusing foods. If you're feeling ill, you don't week. They have a weird cry, but also then this vulgar in front tunnel, which is the soft spot atop of babies that, um, do they have a stiff neck, which is actually the same for kids or adults? Well, did they dislike for it? Lights. They drowsy all of these things that kind of help you put together the picture on. So I just like to go through some other kind of common pediatric presentations. Well, we've done meningitis. There's a few other things you should know about. So here's another case you got four year old girl. She's been brought to your treatment center by her month because she's making some funny noises when she's been bringing their It started 10 minutes ago, and now it's getting worse. And she looks like she's kind of struggling with her breathing quite a bit. So what do we think going on here? Uh, okay. What could this be? A croup is a potential for funny noises from breathing. Uh, swallowed something. What Bobby means, I'm sure that was put me part of of that. Something else. Um, but some of it could be cold. Something stuck. Yeah. So if they stuck something in their mouth and next, any inhaled it a Balaji is? Yep. Uh, got ritis also been on asthma that popped up. That's good. Definitely sounds like potentially be an aspirin tuck. Uh, gum. Maybe it's really hard with this country to put things get a lung cancer making know in a four year old or however old is that they were not Not really in a kid. Um, yes. Generally got, like, kind of our things that I always block the asthma. Maybe there's lots of different things. They're good site. We'll get this be. What else do we want to know about this patient? No, we won't do that. I'm set his history on the observations, so she's got a bit Louise. Um, so when she breathes out, you have It's gonna be using noise. She's allergic to nuts. Seeds. She got hay fever as well. Her medications that you've got an EpiPen. He takes this cream at two different types of cream. One of them's a story. You got extra. And actually, the EpiPen tells you that these allergies might be quite bad. Um, for lunch, she had a sandwich that she brought from home. She's not eating anything up. Event on. There's no allergens that she's eating that she could be aware off on. Be looking at her if she had a wheeze that started a couple minutes ago and it was getting worse, and she's struggling to breathe, so assessment she's able to talk. She's got a high respirator with some retractions and obvious weeds. She got warm for freeze, a normal count refill time. Heart rate's high, but no issues with neurological function, and you got no rashes or skin lesions in the abdomen is soft. I wonder what question I had for this. Ah, yeah. So, based on the history what do we think could be causing this? In fact, we've kind of girls cover, but allergy. That's fine. Um, yeah, Uh huh, That's good. That's where I am with the questions with that So it doesn't breathing difficulties. There's a lot of different, uh, noises on things that people talk about on. A good way to split them up is into weeds and strider. So we use is a sound when people bringing out on it suggests that there's a problem with the lower airways. For a stridor is usually noise when people breathe in on that suggested problem with the upper airways, so we could be caused by things like bronculitis viral ways, asthma. Things that affect the lower airways were strider. It's possibly caused by a condition called Epiglottitis, which would go for the second croup in remission and in hell foreign bodies. So they're putting in the mouth and the accident. You breathe it in one of the causes of ways is anaphylaxis on. This is essentially a life threatening response to an allergen on. But you can probably tell that this baby here definitely looks on while again appearance. If we just look at them and go. They're not really responding that I shut. They've got this rash over their face. They got these swollen lips. They got a BP cuff on them. We don't usually do broke BP cuffs on their blood pressures on babies or even kids. It's not just that, probably quite a while. So just by looking at this good you tuck is, um, well, there's a couple different ways we can decide if it's anaphylaxis on up. So the first way is if we if they don't know if there's any expression on allergen. But they have some sort of skin problems that they got this rash or they got this lip swelling or a swell as problems with their breathing or low BP. They're not have Lexus. And then if they got likely exposure and some of the other symptoms are involved, then I get diarrhea, vomiting, breathing difficulties, low BP, dizziness, rashes, all of those things that Zanaflex is on then, also at Third Way is have a hard and exposure to the allergen on now. Do they have low BP symptoms? Then that's definitely in flexes. Couple different ways of classifying it but you can think about in terms of the symptoms as well. Another bronculitis. This is probably the most common kind of viral infection in kids. It causes so many hospital admissions. Every single winter is an absolute like nightmare, but kids often get over it. So it's a viral infection caused by the respiratory stink, your virus, or RSV, that causes this kind of fever, runny nose, cough pattern. They'll have maybe about a cough over the first three days. Then over the next three days there, breathing get a bit more difficult than they'll get better over the next three days and classically, only last, like nine days. And it's usually in babies kind of aged 3 to 9 months old. Um, really common? Yes, Oh, 333 person on. But generally they don't need to go to hospital. They might do if they've hard like it's, um, Eunice pattern. Or if they have another condition, or if they sat so that that might be in oxygen, you can send them in and then asthma. End of the course of weeds so you don't really diagnose it under five because you can't a peak flow, which is a little machine that you breathe in, that tells you is that you have dilated your lungs are on Diovan instead of 88. Is this classic triad of extra Hey, Fever and Asper? And then, if you have these or no, people have these, and it's often that they all come together so you don't really have extra on its own or aspart on its own or hay fever on its own. It comes with one of the others, or even two of the others on again. You can get some ways difficulty in breathing limit lean forward and try to putting on do you the treatment for it. Basically, give them their own inhaler. Um, but make sure you use a spacer, so if you look on the top right, there's two different forms of spaces. There's like this one of the masking, this one of the chief, but basically the point of the air's. If you use an inhaler without the spacer, you're basically not taking in any of the drug. You're literally just coating your mouth in the back of your throat with that on. But it's doing absolutely nothing. You might get a little bit into your lungs, But it's not really the best if you put it into a space of first and then you breathe in the air from the spacer that's gonna have the drug already kind of aerosolized in the the air that you're breathing in and you're gonna get much more of it into kind of the lower airways, which is where you really want it. Then it got So it s so maybe is in gory pictures if you don't quite like medical things. But I'm not sure if you while you're in the stock, if you don't, um so epic arthritis is now quite right, but it's very serious and infection off the epiglottis, which is your vocal both. It's basically this horseshoe shaped structure and what this does is seals off your track. Your your windpipe air. When you swallow Onda, it stops you from better the inhaling food on in epiglottitis, which is usually an infection with a bug that we can access it against. It really swells up and you can see her if your tube going into the truck. Yeah, If this gi wasn't that, that would be really, really difficult to breathe through Onda. So because of this, you really can't distress the child at all. If the kids start screaming or crying, they're gonna block off their airway. And they just need to get the hospital basically. And these kids will be the look really, really sick. They'll be lent forward that we drooling classically, they went. Vaccination is either, um croup. So backing off on a lot of you've probably heard this yet this barking cough. It's worse at night and classically starts at night as well. With the Strider on the kind of long technical name for it's a viral laryngotracheal bronchitis. Andi, don't go over this. They just They'd probably just need to see someone on get this classic cough. Which way here is this classic barking cough that's west at night. If you've ever heard of, um, if you ever heard that your you know exactly where I'm play again go. So let's go over a procedure where know after you've done those breathing things. So your first aid at your Twickenham exciting. You just walk back from lunch and you hear a lady screaming, You thought you'd be a bit nosey. You walk over and you see There's a two year old child on the floor seizing on. There's a crowd watching, but there's not really anyone doing anything. And there's an idiot holding a spoon. What you gonna do? Let's go over to whole evening. Here. Yes, what you want to do in this setting? It's take the spoon and scale up. Sure. Now you've got very sick kid. But at least you have a sting. Clear people. But make sure the kids say very good thing. Get people to go away. Yep. Get people go away. Good. Um, call 99 kids. Put them on your fi with the head of NIH yet? Name maybe. I guess he could. It might protect them. Recovery position. A kid takes and plays off of that. Loads on. Yeah. Good question. That good answers right at what happened yet Go over history. Tell the child about distressing them. If the mums that come down time, the seizure, that's really good, make sure the head's comfortable. Try to help. Always a good sign. Uh, you think about the bystander effect. No one's gonna help until someone steps in. Interrogate, idiot. And Coleman. And I'm sure like darker position. If you could write yet over 80. Good. Um, assess the and breathing. So your next steps in terms of seizure, you get some help. You don't start stepping in and certainly be like, right. So I'm holding this kid's airway open. They're not gonna be able to breathe without me. How do you like all 999? When my hands are stuck doing this, they get the help first and then protecting from Palm. So put a coat under their head's not your coat. Your coats their to keep you warm. Get someone else's coat. It doesn't matter for random. Bystander is cold. It doesn't matter if you are cold. Think of yourself. First time the seizure. It's really important for treatment later on to know how long the seizure lasted. Because that's a minute. Not. Must be worried this last half hour. Very, very, very worried. Um, consult up crowd. Get them to go away. Um, another seizure stopped. What we got today? Return this, but sure, he could return this being if you wanted to call nine. And you have not done that already. Got a history of event and Charles? Yep. Uh, help Make sure the Charles. Okay, Put into recovery position. Keep the head pillow on the head on back here yet come to trial down if they need it yet or good ones. That was me. Check response of just heart rate and obs. Good. So tell us, there's lots of types, and they're really common in kids. And some kids of that left you can have hundreds of seizures a day, and that could be normal for them on Dauphin if they've had one before, the parents will know exactly what today, and you just need to do what they say. And there's a government of the terms people used to describe, but epilepsy and teachers. So there's a term generalized. So this means that the entire brain is involved on focal, which means only a little part. The brain's evolved, so if they get twitches that focal seizure complex so that is a few means are they aware of what's happening? Complex means they don't what's going on, but simple means today tonic clonic. So that's your classic. They go really stiffer than their shaky seizure, uh, absence. You get kids playing the runaround, stop and then I carry around again and they weren't really having any idea what just happened when they stopped myoclonic, which is just a way a basically meaning minor means muscle clonic means seizure. Basically so muscle seater you get. Just get muscle twitching and atonic again. So tonic refers to do you have any tone in your muscles? Are you tensing them in any way and a means? You know? So these are called also could, like drop attacks. So could it be walking around the stop and therefore flat on their face? Um, on do in younger kids, there's a thing called fever convulsions you might have heard, which is kind of like a seizure. It's not terrible embassy, but it's a coping mechanism for a fever. You get this classic history of a baby who has been on well for a couple of days. They've got a little bit of a viral infection. It sounds like on then you have a seizure because they got temperature and then seizure stops. Um, parents get really worried kitten tight in a on any sense of home because they're fine. Generally, they're really safe on most all haven't, but most of them will go on to have another seizure. It's just because babies can't really regulated temperature very well on their brain. Panics. And Alice of a seizure? Why not? But it is. There is a little bit of risk of epilepsy later on, but it is generally tiny at this video. Explain really well how you control it. A convulsion. Protect them from injury. Do note for strains. Reduce their temperature by removing clothing. Okay, you got when the seizure is over, help him to rest on their side with their head tilted back. Same as with animal seizure, protected from home. Call ambulance and then call them down after because they were, like, could be really hot. Just take them down to this kind of under layer, though. Don't get them, like, completely naked. Because they'll freeze babies Really weird at regulating their temperature. Just take off the arthritis. Yes, we cover this psych. Not all seizures in ambulance. Um, the seizures that do our first seizures if a seizure last more than five minutes or more than their normal. If they have two seizures in a row, that suggests that they actually haven't had two seizures they have one on. They've not really fully recovered in between. If they are postictal, which basically just means the drowsy phase after seizure. So if they are in that for a longer than normal, when do they have any other other injuries that might even to get hospital? Generally treat principles are get some help on day afterwards, they'll probably be unresponsive to know how to treat that. Let's get the left one an interesting time. Uh, yeah, so there's times we'll just kind of quickly go over pain in the kit. So there's lots of different ways of assessing pain and cats, and generally they don't really understand what pain is up to a certain age. They won't really have any idea what what's going on there won't be able to process the fact that they are in pain and then communicate that to you and tell you that your, uh, they're in pain. So this couple of ways we can do that in a baby. But here's the thing that aflac scale look up, which just looks at a lot of different kind of objective measures in a younger trump use the behavior. So are they lying down screaming, refusing to move? Not that you touch it something. Then age 48 years, These one baker fetus. So does it not hurt a little bit? Does that hurt? But more? Does that hurt? Lots on. They can kind of point to their one. You could ask them to point where it hurts, and that might be quite used for them. I understand that Onda functions of What are they? What's the pain? Stopping them from doing things like sleep and running around and playing with her friends on a good weight goes so with this pain started running, but it's not from walking, but it stopped you from sitting and watching the TV on, but it stopped me from sitting and watching the TV. That's probably quite a bad thing on quickly going of a resource. So basically, in little, kids get all of the help you want really, really, really quickly because sick kids look fine for ages on, then they certainly don't look fine on they crash on. They go off really quickly, So the principles for um kind of resets at kids in this video, your breath open their way by hitting the head back with one hand on the forehead on to see if it's under the chin because any obstructions from the mouth clear the airway. 40 If you can clearly see something ahead of this position pages. So part of the nose are all the multiple open ticket place, um, Syria. Mopping around. There's You're still into the mouth. Given a west breath in about one second progestin rights, you move your more from there's I want. Give them five initial rescue breast out about for a second like this. Just compressions, sneeze or mother child beside the chest. This only one hand on the center of the chest. It's, you know, the child with your arms straight on president vertically, one third of its day. What is the pressure? I love the chest of Come back. Oh, should only moving your hand from the chest. Repeat this to get 30 test compressions at a rate off 100 to 120 BPM. This is quite fast to help you. You can saying never the anything. It's gonna help you to keep up with the pits, so you get any of that. So five breaths first and then 30 compressions on two breaths. But make sure you got all of the help there on the way. Onda his resource in the little little above us, Hopefully this be kind of quite entertaining. They be Cbre's crucial to know there's a few simple steps. So here we go get take a charge for school. But why don't you wait for the ambulance to arrive? Paris and tips to have your baby survive, Please Your baby on a nice flat service until their head back. Don't be nervous. Nervous? Oh, give five months over the mouth nose. Not sure what we mean. Well, here's how it goes. One too fast enough to place two fingers upon the chest times. No way. That was fun of information. Her work here is done. Oh, I need a vacation. The most populous used to be kept in a cupboard where my central ambulance unit met and they used to freak me out. But there is Yeah, house and John addresses CPR in kids. And that actually works. Feel free to look that up. Just send an ambulance, baby CPR on. Do you want other videos to it? Like entertain kids? You got all of these fun ones? They're, um hopefully this'll means that we can go on to the quiz. Exciting time. So back onto Poly VI. Um, I just find the first question quickly reshaping your poly VI link in case people will exit it. Yes. Yeah. Free shadow in the, um yeah. We sure that in the, uh, think he's que and a That's the one. Um, So you got for your child they present with a non blunting rash and a fever. What are the sign? Would you expect him to have? I'll just go until we've got, like, 10 or 15 or something, and then I'll show you The answer is say, for your child. Non blocks, more action, a fever. What else would you expect it to have? So spots on the hands photophobia constipation or pins and needles 12. 70 somehow gone down if you get to 15 for the answers. Anything else? Not put their turn? 13. So what we got? So most people have spots in the hands. Uh, some people have a phobia, but not lots of pins and needles. Some reason, uh, something to take away the insulin pens. Any does constipation? Actually, correct answer is photophobia. So non blocks Russian a fever. You think meningitis on? They're gonna have to be scared of lights. They know. I, um, next one. So you got a seven year old child. They presented the treatment center with a limp. You started yesterday. You do this? We're not really limp. Uh, ready that are on. Yeah. You notice the child is not responsive, Not breathing. What are you going to do? First? Get together and let's go to 15 again so you can get 15 a 15. There we go. Um, so how we go? So some people saying call nine or nine. Good. Uh, get a D start just compressions or get five rescue breaths. I think the answer is five rescue breaths. Um, in a child, when you're doing recess, you want to give thumb. If this isn't your to get other people to call 999, you don't read it yourself. And you want to be saving the left. This kid basically. But if you're on your own in adult, you call 901st, but in a kid need a minute of CPR because often, if they're only if that kind of breathing has gone off, you might be able to just sort of give them the breaths can kind of really helped a lot at a minute. See if you might be enough. It's gonna help them. We're going to give the minute CPR first and then call 99. And of course, he did five rescue breaths than 30 today. Um, what's the best way of assessing pain and a five year old child? It's got flex school, one Baker faces or full Socrates history. I mean, if you got a full, it's 10, maybe. Okay, so we got We got most people saying Faces on. That is, in fact, correct. Um, watch of the's is the most worrying observation newborn baby. So if you click over the one that you think is, um, abnormal, always worrying, Ah, purposely not giving you the Rangers. Most people actually saying the heart rate actually for a newborn baby 140 is absolutely fine. Some people said temperature again. Thank you for 36.5 degrees Celsius, absolutely fine for baby trying, for everyone knows, said SATs of 98. Of course, that's perfect. Only two people have said risks of 16, Um, no. Three and four and all of, you know, set up. Um, but yeah, risks of 16. Whilst that might be normal for a little for a baby, that's really, really, really slow babies breathing like 40 to 50 rest a minute. Um, we have What are the three parts of pediatric assessment Triangle shows that appearance breath, sons and Sinuses. Airway breathing in circulation. A parent's breathing in second. Oh, away breathing and Sinuses That's even get 15 Chevy answers. No, it's 12. So, yeah, most people said appearance bring circulation. That is absolutely correct. That sorry. Ah, the which of these is the most worrying sign? We're almost done. I think it's this one of the questions. 56 10 One more. There we go. Perfect. So people that weighs mainly, uh, answer is that the stride all ways to get some Probably be sick. Um, and they have a bit of a problem hard time breathing. But the problem is, with their lower airways, with stronger there's a wrong with the upper airways on D. You're gonna be fine if some of your lower airways are blocked, not working. But if your truck here is blocked, you're gonna have problems. So that's a lot of questions. How would you rate your pediatric? No mention. Now, hopefully, it's a little bit better if you just click on the area. Um, that you think you can have all it's Yeah, excellent. Good friends kind of saying that a top. So that is everything for me. I just got to take away points. So in terms of kids, be friendly, Ask about the same toys I spent the name of that toy or that better build a bit of a report with, um, appearances key. Look at the kids. Do they look sick? If they look sick, that probably sick on trust. The parents. They generally know the kids best cause they're the ones that have been kept up. Buy them screaming for us. However many yes, Onda his further reading if you want to look it up. So obviously, since your numbers website has a lot of resources for how to do first aid, some of the repeats related this is like, Well, don't forget the bubbles, which is a little medical but is really useful. There's a game called cards against Pediatric Dermatology. If you are really that king, if you want to look at recess. There's the recent Council UK that Hubble the guidelines on that there's a podcast school, two peas in a pod there to pediatric emergency physicians. They kind of talk about pediatrics on different topics. That's really interesting on day. Spotting the sick child. That's a website on on how to spot the sick child. So thank you. I don't bother with that. Free battling. If you do feel thank you. If anyone any questions, you can stick them in the queue and a on I'll go through some of the ones that people just already. If you got feedback, Freddie will be sending up a link. I believe. Yes, that should be a feedback link in the ship's somewhere. I'll post it again if know about email out literally now that send just quickly go through some questions that people were going to read them out for him, but you're on. So what's that we see for these? Answered. That's a dangerous once know everything. Circulation is your approach to like every patient, uh, in that order. It respirators number breaths per minute, yet SATs is toxins, and the blood's that. How do you calm down Children who are afraid of injections up. This is the one I was leaving for. You thought you'd like this one on. So the key point is to get them familiar with it before it happens. And whether this be talking to them about or getting that toy and doing this procedure on the toy or actually, your best friend here are the play therapists. They're the ones that you want for this. They're trained to basically explain to kids how they're different procedures and how little all that treatments are gonna work. So they consider the kit. Beforehand you go. You know what? We're going to come on and we're going to need to put a tube in your arm on. But I'm going to show you how we're gonna put your chin on your own by sharing you on your back on. Then when the kid comes along later, they're going to scream and shout. But they're not as much because they they're aware of what's gonna happen somewhat. Obviously, only what's it start in ages of kids, but yeah, get your play therapists involved. If you have them. Um, I remember once once or just on that one I remember once install helping install a stoma on a bear because the little girl had to have a stoma installed in her abdomen. And so the bare got one. A swell. Yeah, yeah, definitely things that I like. If that has that scars. The same is the kid. Croup is actually a an infection off parrot influenza or influenza, but yet it's viral laryngotracheobronchitis. So it's a foreign infection off the larynx. Your your voice box your truck here, which is your windpipe on your bronch up to Maine Bronch. I, um Why do you said I don't need to space that they all do. They just don't use them and carry them because they're inconvenient. Yes, you could say that adults are better off like there might be able to coordinate the whole inhaling more has been no studies on this. And that inhaler is really not good with that spacer. Everyone should use the space up so much better. Um, do you stop for a B cell? It will work in the hospital is a good thing to be aware off. Most people just go for a B C. D. Because you're kind of assuming that maybe there isn't a truck coming towards you or the isn't active fire. They should still be in, like, the back of your head. But yeah, Dr. ABC is usually more used more for out of hospital. Kind of pre hospital stuff. Um, what about a block? Succeeded, I presume They're just seizures based on as you get things for breakfast. The attacks. So it basically just off get so mad they hold their breath, Onda then collapse on, then, um, yeah, they start breathing for themselves again. I don't really know where they do it, but that's the thing you could see on oxygen. Use is, I guess it just really, really sick. Kids with low sats. They might have a seizure, but that's no is comments. Rest of them. One is a child child in terms of CPR. Generally say we say neonate or baby is up to one child, is then up to the age of puberty and adult is over puberty. But realistically, guess roughly what might work at city two fingers for baby, one hand for a child and two hands for, um on, uh, adult. Try to get right. Well, if you have a teenager or something, and you're trying one hand and you can't quite get the depth you want. Go for two hands. If you've got a baby, he's like 1.5 and you've tried 100. Think it's a bit much good for two fingers, just like see what works best in the situation? Really, Um, is it true that eighties have a small chance of being effective? Because most of time people are after you eat yet, basically, you need to shock someone as quickly as physically possible if you can watch them go down, and somehow I have the pads on them as they're falling a shot with then even better. But realistically, time is brain on timers, heart, muscle and timers, all of the other parts of the body. For all of the time. They're not getting oxygen because the blood heart isn't pumping. They're going to start dying on recently. After about four or five minutes of that, your brain is not gonna be as it was before. Um, so and also say, in terms of I don't cardiogram, it's less if it's. But most other cardiac arrest are what's called a systole. So where it says. You're 50% of them are where your heart just stopped. There's no electrical activity. You can't shock that. And 80 won't shock that. If you shock it, nothing will happen, because when you shock the heart, you're sucking it to cause a systole or you're causing it stop and then hoping that it starts on its own. Whereas the other half of the arrests will be VF and Bt, Inferior heard off the tricky defibrillation and ventricular tachycardia, which he can shock eso. There you go in half of all kind of arrests eighties after useless. But you don't know until you try. Um, I think it's all questions off any remaining questions. It's just that last, again, again about injections and procedures, and I think just worth mentioning that sometimes the child's not going to like it, and sometimes it is a case of best interests. We've got to do this for you, and you just try and make them over a comfortable as possible or it's safe. It's possible to carry on. Generally the parent pinning him down on the lap is the best way, and that their hugged and then healthcare assistant holding an arm or something. And then everyone sings Baby shark. A really good way, actually is if you get him to hug them, Um, and then if you put one of their arms underneath, their moms are, if that makes sense when they're looking them. So if you think the kid is having them, um, and the kids like shoulders and arms just underneath the mom's arms and then you basically have the bump, inning the kid down and you can do it from there. But really, a lot of kids generally take one injection, and I'll realize, Oh, that's painful on the rest of went for you. Very nice, but you can go and try and get the kid to explain it. I kind of understand the situation, but more. But yeah, as Freddie said, it gets to a certain point where it's not gonna work. You just have to get on with it. It's in the best interests. They don't have capacity. They can't really tell you what's going on. They gonna forget it by this afternoon because the kids that mom's gonna go and buy them like an ice cream or whatever, like you just kind of get on with that? Yeah, it questions anyone's go that way. How How effective the destructions, everybody, just to experience them completely. Depends on the age. I think on the kids destructions aren't gonna work in a teenager. Probably a great story or no one on day. Yeah, again, if they're a bit older, you can explain it that explaining to a three year old I'm now going to put a needle into your arm and this needle, Let's we put a small plastic tube through it and then I'm going to take out the needle, and then you go after a small plastic you to have the antibiotics for infection. They're not understand that, but they if you have some bubbles off to the side of them in a big video of and lien on generally baby shark playing poor patrol. Yeah, other other Children's TV shows are available, which have what is your preference? Um, I remember when I was about 13 14, I went for a booster jab. I was really afraid of needles at the time, and the nurse giving the injection decided to get a look. There's a wasp and point the other way. As she went to jab May. And I went to swatted her thinking that she was wasp. Yeah, so, no, always great. And no, it's, uh Yeah, they go someone. So it says the doctor worked. Or someone doctors. The destruction. It worked. Yeah, distractions. A great the can work. They also just my No, um, it's only about to be a bit honest than deceptive. Yeah. Anyone with a lost questions, I'll give you about two minutes, and then we're gonna end as always, Anyone with questions. You're welcome to email me. Them Obviously. Direct feedback. You're welcome to email me that. I've got put out various feedback links. Please, please, please do give us feedback. We didn't look at it. Would you listen to it? We do try and improve from it both in terms of how we teach and in terms of the actual structure of the Siris. Um, especially if you have any feedback on how they're kind of interactivity of this one when compared to the others on bowel, the pollen levy work for everyone. I think there's a little bit of delay with what I'm seeing on what I'm doing and then how it's kind of relating so if that could be improved in anyway, let's see. We've got a little bit of that already, and I'm having quick read of some of them is they come in and we are. Yeah. So you're about 60 more seconds going to start sticking. Useful stick is useful for everyone. Get everyone a sticker. Like, if I went to the doctor for a blood test and they gave me a dinosaur stickers, I would absolutely take it. Yeah, on. But I also do some Kovacs like vaccinating and the amount of people that want a sticker after psych everywhere was giving us they could sneak over vaccines. The one that's brilliant is a lollypop. I would do a lot like I will happily have quite a lot of injections for a lollipop. The better stickers you have, the better if you got dinosaurs. Cars are animals that good? I was brave today. They're pretty good medals, ones that look like medals. Fantastic. You can tell the GP to have done. They do a lot of like pediatric patients because I got good sticker draw. Okay. So with that we will finish. Thank you everyone for attending and we will see you all next week. Thank you very much.