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A up can you see the powerpoint? I was, there you go. You should be able to know. Perfect. Um Yeah, and I think there's a chart as well. So if you have any questions, um just pop them in the chart and then at least you can uh feed them back to me. Um But yeah, I'm a co ct one. So core surgical trainee working exeter. Um I'm currently working in colorectal surgery and I think I want to sort of pursue a career in general surgery. Um My first f one job was colorectal. So I did surgical course quite early in my F one career. Um And then equally when I started F two, my first job was urology, which had general surgery on courses and I was, my first job is in us. Um So I have like quite good experience um sort of doing on calls, like quite early on and I know it can be quite daunting and some of my other f one colleagues find it quite daunting. Um They can be sort of some of the busy shifts you do as an F one or sort of in your foundation career. Um, so I was just gonna do a brief overview of sort of how the on-call works and then just, um, it's not gonna be very heavily clinical, it's not gonna be very long, but just some pointers. Um, that sort of like most of the things you're gonna see, um, surgery is like very repetitive. Um, and it's quite formulaic how we approach it. Um, so hopefully in the information I'm gonna give you, you'll be able to approach of 80% of the things you're gonna see on an on call. Um And if you've got any questions on the way, just let me know. Um, so what we're gonna cover is how sort of an, how a surgical on call functions. It's slightly different to how you work in Ed or how you work in acute medicine. Um Your role is an F one within the on call and just some important things that will help you when you're taking history and caring surgical patients. And then I'll quickly do an overview of most of the common presentations you'll see. Um And I think, yeah, this covers sort of like 80 90% of what comes in and then just any sort of like general tips and like mistakes I've sort of made on the way. Um So how surgical on call functions is usually you sort of part of a team. Um There'll be an F one N sh a registrar and consultant. Um, this will differ a little bit from what trust you're in, how big your trust is. Um, but you sort of function as a unit and between sort of the three of you, usually the F one shh. And the registrar you're responsible for sort of taking all the new referrals, seeing those patients clocking them, uh, you know, requesting scans following them up. Um, and ultimately diagnosing, discharging them. Um, if you've sort of, you might have done an elective an ed or you might have started on medicine, this is quite different. You're sort of just caring on your own and then a consultant comes to post to take them, then the patient goes away to, you know, gastro ward, respiratory ward and you sort of forget about them. Um But the patients, you see, because you sort of function as a unit, the patients you see are sort of your problem for the rest of the week or not a problem, but they're the patients you're gonna be looking after. Um, it's usually a 12 hour shift um going from sort of like eight till eight usually. And then, then you hand over to the night team and they essentially are clocking for you whilst you sleep and the patients that they clerk are then gonna be on your list and sort of your problem the next day. Um And then equally hand over at 8 a.m. clocking is usually split split between the F one and the sho and then every patient you see should have a senior review. Um, because a lot of your sort of ward work as an F one is, um, you're sort of just doing what the consultants told you to do on the ward round. It can be quite daunting to sort of cut new patients, make a plan, make your own plans, make your own sort of diagnosing decisions, um, which, you know, people can sort of shy away from, but everyone's going to get a senior review. So you might as well just sort of like plug for what you think, what you think is going on and make it like a positive learning experience. Um, your consultant like might come around sort of, um, if there's patients that are sick, they might need surgery, sometimes they pop down to the ward, like to review them and when they do a post hit ward draw on the following day, which I'll go into explaining, you'll see them then, but then not usually an integral part of the team. Um And then you'll get referrals from Ed and GP throughout the day if it's a weekend, obviously, probably not from the GP. Um And then usually you'll be sort of clocking and your sort of, you'll have like a surgical assessment unit or a ward that functions as um your assessment unit. Um And then, yeah, so when I started off on, I didn't really understand this when it what came up on my rota and again, it's different if you're on call at the weekend or you're on call during the week. Um, but you usually have a take day and when you're on take, you'll be seeing all the newer refers that come in from D and GP. Um, and then usually the day after or very rarely, we don't need to worry about this at this point. If you're a medical student, you might be doing both but you, when you post, take us out the following day. Um And that's when you'll have like a ward round of all the patients you've seen from the consultant. Um You'll basically spend the day like chasing results, chasing um scans and getting, you know, people discharged or admitted. Um So that day equally, even though you're not seeing new patients, um it might be quite job heavy. Um uh again, depending just so you're aware, I think you have a separate talk on vascular neurology. So I won't really cover it in this session. Um But uh when you're on call, you might be responsible for seeing patients under vascular urology. So it's important to know in your hospital how you then refer to those specialties. Um I would caveat this. So, um if ed for example, when you and say you've got like a testicular torsion or ischemic foot, these are emergencies. So they should probably be contacting the receiving specialty directly. Um So don't be pressured to if you think something doesn't sound right. Um, yeah, don't just go along with it and then I just want to mention this as well. So obviously when you're doing general surgery, there's lots of emergencies and they usually your hospital will have one emergency theater. Um, and this is usually called the C POD theater. Um, essentially this is shared with all the specialties in the hospital, I think also usually have their own ones. Um, but they'll, you know, essentially at the beginning of the day, all the sort of specialties fight over what list. Um, they do this, the, um, the surgery in which, um, yeah, I just want to mention it because, like, a lot of people mention like the sea pod theater, the emergency theater. So, just so, you know what they're sort of on about. Mhm. So, your role as an f by one when you're on call, um, essentially to get experience clocking surgical patients presenting them to your registrar coming up with plans, um, and then chasing the results. Um, and, you know, seeing if your diagnosis is correct. Um, it's quite, I think it's quite good compared to if you work in Ed or work when I worked in, I did acute medicine as an F two and you sort of cut the patient and then they sort of disappear off, um, in surgery because, and they're sort of stay on your list all week. You kind of see the continuity of, you know, was it? Right. What you did, how have things changed? Have they got more sick? Do we need to alter the plan? Um Also your job is an F one likely at some point, either if you're on call overnight or you're on call in the evening we'll be doing ward to cover, um, in the chest. I, in now, I think after five, the on call, F one covers the wards in my old hostel. There was like a, a sort of evening F one that covers the wards. So you just had to take over after midnight. Um, but it's just important when you start your F one job, you know, sort of what your, what your role is. Um, and also how you receive referrals. Um, a lot of hospitals have like an online sort of task board. My old hospital had a sort of, um, iphone thing they gave to the F ones. Um, and then unfortunately the, this is a bit of a rubbish F one job, but often the task of keeping up to date with the list, um, falls upon the F one. this is important for a number of reasons. So when you hand over eight, you need, if you've kept the list up to date, you'll know all the patients what jobs need chasing. Um, roughly a diagnosis. Um, like I mentioned earlier, surgery is very repetitive. Um, you'll soon come, soon, soon come to learn. So you might have seen sort of, you know, five different patients with rights pain appendicitis. Um, and if you haven't sort of put some details on all the salient bloods, um, you'll lose track of which ones which, um, and actually when I was in one, I think, um, I sort of got two discharge summaries mixed up because, um, so I bit so busy and I hadn't kept the list. Right. Um I think they were both called Jack. One of them was 18, 1 of them was like 21 had, had an appendix and one had like abscess drainage. Um, but I wrote the wrong discharge summary for each patient just because I was so busy and like uncles can be really busy. So if you don't keep your, your list sort of up to date, this is where sort of mistakes can happen. Um, obviously with the discharge summary, it wasn't too serious but, you know, it could have been something a bit more. Um, so the main issue is your face and this bit of the presentation is a bit dem and gloom, but it does get better. So, um, they can be very busy and some people are suited to like a fast pa sort of busy working environment and I really enjoyed it enough. One, which is part of the reason why I decided to do general surgery and before that I wanted to do like ophthalmology. Um So, yeah, I did, I did really enjoy the pace and sort of dealing with sick patients as well. Um, you might see like 30 to 40 patients in a shift. Um, which is a lot, um, given it sort of like a 12 hour shift, if you can be that when I, when I did me as enough too I used to spend about an hour clocking a medical patient from start to finish. And so it been a night shift, I maximum see probably like seven or eight patients. So it's, it's quite different. Um, it's very fast paced and obviously some people, they can get a bit stressed if they don't keep on top of their jobs and on top of the, on top of the list, um, the important thing with this I think is don't feel like you're being rushed. Um, if you've got five, you know, five patients to clock, don't try and cut them really quickly and do a rubbish job, just cut them at your own pace and make sure you've done a thorough job. Um, all the patients you don't clock essentially going to be handed over to the night team and nights are invariably for clocking, maybe not covering the walls, but the sho clocking is gonna be quieter. So, you know, they're not going to mind clocking for your extra patients and they're also fresh, they've started their shift in new, like they've not been sort of running around for the past 10 hours. Um, so, yeah, don't, don't feel like you're being rushed and prioritize obviously the most important things. Um, surgery has a large number of, um, ambulatory patients and the, um, patients tend to be younger. Um, so you might have sort of like a sort of surgical triage unit, um, with a waiting room. Um, so have, they're not sort of in beds where you can sort of see patients quickly send them home overnight, bring them back for scans, bring them back for repeat bloods and review how the pain is doing, which sort of adds to your bulk of patients again, which is quite different to medicine. Most of them are quite elderly and once they sort of got bed in d they're sort of here to stay, um, they're also, they are, the patients do tend to be younger. So sometimes they're quite keen to sort of get seen quickly. They want to, you know, know, a plan. So they might be self employed. They need to go back to work and they might have kids at home and they've got no one to sort of find them in the, in the evening. So sometimes the nurses will be sort of like pushing you a little bit to get plans and get patients discharged. But it's important, like, just to not, um, sort of let that stress you. Um, and yeah, you, the probably the biggest thing when you'll be, find it most challenging um, is obviously you function as a unit, which is quite nice. You always have a shn, a registrar to, to escalate to, um, usually they'll buy you coffee and you work with a nice little team. But then if there's an emergency surgery to be done that pulls your h registrar to theaters. And so sometimes you're sort of left alone, sort of on your own as an F one. which can, again, can be quite daunting if you're not used to it from when you're working on the wards. Um, and this can be for quite some time, like sometimes when I was sort of an F one or an F two doing on calls. Um, you know, if they've got like a laparotomy, it might be three or four hours and you're sort of clocking patients and you've got no senior review and then your reg might pop back for sort of 15 minutes and then get called to do an appendix. So, on those particular, on the post take days when you're doing most operating. Um, that's probably, that's the time I probably found most stressful. Um, but I'll talk a bit later about ways you can sort of get around this, get sort of senior help and stuff like that. Um, and then even when I was clocking, I was on call sort of two weeks ago, this is a CT, um, I had like a lot of pressure from the nurses to like get plans and stuff. Um, but it's important as enough one you shouldn't be discharging patients on your own. Um, all your patients should be senior reviewed. Even if I had a, you know, even if I'm a CT now and even if I had a patient that, you know, had normal blood to normal scan, if I wasn't, if I hadn't met them before, I wasn't sure of the plan. I wouldn't be confident just discharging them. I'd want to check with my registrar. So it's not sort of don't think you're being useless or anything by not being able to give them plans and stuff like that. Um Yeah, that's probably the worst slide. And I have, I have seen some of my f one colleagues, to be honest, when I was in f one sort of crying, breaking down, getting very stressed on surgical calls and usually it's when there is a mixture of all of this. Um So they're like the nurses have been particularly pushy. It was very, very busy. Um They sort of, um, they either didn't have a reg around or the regar was a bit dismissive. That's very, very rarely that happens. Um So that's part of the reason I wanted to give this talk and hopefully that'll give you some tips to avoid that happening. Um because it should be a really positive learning experience. Um So things that will help you in your, um on call to sort of make it easier for you. Um, so the main thing is to send good communication with the rest of your team. Your, I and your reg, I think every time I've been on call, um, my reg and, uh, has given me their phone number, usually we've set up a whatsapp group. Um, and even when I was, I was doing nights at the weekend and it wasn't even that busy, but me and my registry were like, constantly messaging like, oh, I'm just going down to d I'm just going to theater. I'll be back in the office in 10 minutes or whatever and it's just good. Like, so you always know where people are. So if I did need to get in contact with her, now, she's in theater. So I need to call through to theater. She's not going to answer her bleep or, you know, I can just come up to the ward and speak to her phone and speak to her directly. Um, yeah, that kind of, um, covers the, the next point is always know where they are, particularly if they're in theater. Um, if all your team is in theater and you need to ask them something, you've got a sick patient, you just don't know what to do. Um, you can contact them whilst they're operating. So either if you bleep them, uh usually the scrub nurse will pick up their bleep and, and will answer the call, either they can pass over a message and they might say, you know, I'm going to be out in 10 minutes which is closing or they can put the phone to their ear or they might tell, you know, can you contact the, on the on call consultant because I, I'm too busy or XY and Z. Um, so, yeah, it's, it's really easy to get around. Don't be afraid to message them when they're in theater. The update the list as you go. Um Sometimes your shh should be good at this, but sometimes the registrar won't uh won't be as good. Um It's just useful. So if your regimen went down to ESOS to see a sick patient, they're like, oh, can you add this patient to the list? Just get a brief, um, you know, overview of like what the diagnosis is, what jobs you need to chase because equally if they have to go to theater, it's gonna be your job to chase the scans, um and chase the bloods and they won't be able to. So, um it's just so much easier if you update it as you go. Um And then keep a clear list of jobs because you'll be clocking throughout the day. Um And then when you clock, obviously some of the bloods might not be back, they might be waiting scans and then you're clocking new patients and it's really, really easy to get everyone mixed up and sort of lose track. Um It sounds obvious but don't make decisions you're uncomfortable with. Um know your uh how to get hold of your antibiotic guidelines for your trust. Um Most a lot of patients uh coming under surgery will have some sort of intra-abdominal infection, either cholecystitis, diverticulitis, et cetera. So just know the antibiotic guidelines. Um Part of the thing I wanted to mention, uh don't do things you're uncomfortable with. So I will make decisions is most patients will, the nurse is, are quite good. They'll keep them. No, by mouth when you haven't seen them just in case they have to go for a surgery. Um, they're just be aware of this if they've not been reviewed by a registrar. Um, there was a time I had a lady who had, had an ultrasound showed cholecystitis. I was like, brilliant got diagnosis and she was like, oh, I haven't drunk all day, can have a cup of tea. And I was like, oh, yeah, amazing. Um, you know, have a cup of tea with her and then about a half an hour later, my registrar came in and was like, oh, you let this woman have a cup of tea? Um, we could have operated on her, taking her gallbladder on the emergency list. Um, and, um, which is actually really rare, like, not a lot of people do hot gallbladders. They usually wait for it to the case. Start to have settled. And I had to admit, yeah, it was me. She did get it taken out the following day. But I just, like, obviously I look like a mug, um, and the emergency list is always changing. Um, quite often. So I'll talk a little bit later about this but, like, you might have an abscess that's come in. Um, and if you find out, oh, yeah, they haven't eaten all day or they've just been sat in Ed and they've not had any, you know, food or water for a few hours and their space they might want to do in the afternoon. Um, another thing is, well, I don't want to criticize our ed colleagues. They do a really good job but don't. Um, as an f one often I thought like, oh, the GP has been a doctor for 20 years. They've seen hundreds of acute abdomens. They're much more experienced than me. They obviously must made the right diagnosis and clear the Ed if you see a clock and it's like SC 3D reg. Um, I'll be like, oh, they must know what they're doing. Um, but as you know, there's two things here. So in Ed, essentially you have to remember if you think you're stressed on a surgical, on call, they're sort of equally as busy and often they've sort of got quite strict targets about seeing patients within half an hour, seeing patients within an hour. If they see an abdomen, they're just usually think, oh, brilliant. I can get them out of my um, department and send them to surgeons. Um, so they might have had a stab at making a diagnosis. Um, but they might not sort of look deep into their history. Um, lots of times patients have come up, they've not prescribed the right antibiotics, they haven't requested the right scan for what they're querying. And this is from, you know, ed genius. Um, and, you know, made, made the wrong diagnosis and, and then when you're presenting to a registrar and they're like, oh, why have you done that? Why have you requested this scan? And I said, oh, well, they, you know, the Ed registered it, you just look like a mug like you can't really um defend yourself on that, that decision um equally with GPS. Yes. A lot of them are very experienced. Um And most GP referrals I accept, I'm not difficult with GPS at all. Um And there's lots of things you can't, you can't do blood, you can't do sort of um same day imaging in the GP practice. Um But they might not have met the patient in person. They might not have um you know, ever met the patient before where I work in the Southwest. We get a lot of holiday makers so they sort of haven't got access to their medical records or anything. Um We had a patient. Uh This was when I was on call was, I think he was in a care home and the came and said, oh, yeah, he's got really bad abdominal pain. Um, in the right upper quadrant, he was like, yeah, this, um, patient's known to have gallstones. He must have cholecystitis. I was like, fine, just sent him in. Um, but he hadn't met the patient when he actually got here. He actually had a chest infection. So it was, you know, if he'd just seen the patient, it would have completely changed the diagnosis. So just don't, um, don't have like a tunnel vision, I think is the point I wanted to make. Um, and then also don't be afraid to contact other people. So if you register on a busy, they're down in with a sick patient, they're in theater. Um, if you've got like another reg around another surgical reg, there might be a post take one when you're on call or, you know, your normal ward reg just to, you know, run something past them. Don't be afraid to equally out of hours. Um, I either, you know, you can contact the medical registrar if there's certain things. Obviously, if you're clark, um or you've particularly doing more cover and say like the patient's, you know, abdomen is like toh his and there's bowel contents on the floor. The med ed isn't going to be that helpful. But things like, um, if you've got like a POSTOP fever, POSTOP shortness of breath, um, fast af um, these are things they can, they can, they are able to help you with. Um, and they're used to covering the whole hospital getting questions from every specialty, every surgical specialty often asks the med edge when they're stuck. Um So they're really good at giving you advice over the phone even if they're not gonna come in person to see the patient. Um, and it's a good place to start. So, you know, sort of what to do and then you can escalate if it, if it gets worse, always prioritize the sickest patients. Again, you might have 10 patients to see in your triage, but there might be one that's, you know, really sick, but they've not been waiting as long. Um, you have to see these first, they might get annoyed at you the other patients waiting. Um, but if the nurse is worried, you need to, you know, keep everyone safe. Um, equally the sick patients, often the ones that take you a bit longer, you might have like three abscesses. You're like, yeah, I could quickly see these and tick these off the list. Um, but you need to prior times, the sickest patients. And then again, a big one for me is like, always bring food with you. Um, at least snacks if you're gonna like miss your lunch break or go for a late lunch. Um, you're well within your rights to Exceptional Pool and it's not like, um, nowadays it's not very like Gen Z to miss your lunch break. But it sometimes happens like when you're very, very busy. Um or you've had been, you know, been asked to review several sick patients in a row and it gets like three o'clock and like you're trying to document and your brain is just not working if you just have some snacks available, um we can just keep you going until you can like go and buy a sandwich or whatever. Um because I've been caught out like loads of times and then, sorry. Um I've just been like really stressed and also in a bad mood and also hungry and it just adds to your trouble. I think that's the end of like all the sort of difficult slides. Um So I was gonna cover salient bits of the surgical history. Obviously, I know you probably all know how to take a history. Um It's really not difficult to take a surgical history either. Um You probably see your seniors doing like 5, 10 minutes, they like three questions and they're done. Um In me, obviously, we're a bit more uh people are a bit more detailed. Um But these will sort of just help you. So, um the main thing obviously is history or presenting complaint, um particularly going back to your Socrates it, I know you've sort of learnt it med school like, oh no one like sits through the whole thing but things like the onset of pain, the nature of pain like completely if you don't know what's going on. Um, which often you don't know in an abdomen, it completely can change your, um, sort of differentials. Like, is it sort of, do it sound like they're per, is it colicky? Um, and looking at previous admissions as well, um, this essentially when you're doing history, you need to just like, go looking for the answers if the answers are there just like, take them. So if they've previously been admitted with, um, they've, uh, with radical quadrant pain, they've had an ultrasound showing gallstones and they present again with radical quadrant pain. Chances are they can have gallstones. Um, certainly, you know, they might have recurrence or bowel obstructions. So, looking at previous admissions can not really, really help you. Um, their past surgical history, um, don't forget to do this. Um, obviously if they've had previous surgeries that can often affect their presentation. Now, um, it's good to know if they've had stuff removed. If they've had their appendix out and they present with wrist pain, they haven't probably got appendicitis and which sounds obvious, but if it's missed, like you'll just sound like an idiot. Um, and particularly so the surgeries that they've had, um, you don't need to look deeply into the op. No, no sort of the techniques they used. Was it open or la laparoscopic? But if you just know sort of what surgery they've had, um, was it emergency or elective? And did they have any complications most patients, to be honest, will remember I had a surgery and, you know, I ended up staying in hospital for 33 weeks after and, and they put a drain in and, you know, I was bleeding afterwards. Um, this can sort of, um, impact your, the presentation now and give you like a few clues. Um, a good example of this. I was on call last, when I was on call last week we had a lady who had, had a power single hernia repair, had, had collections after her. Um, hernia repair actually ended up going back to the theater, having them washed out. Um, and then she repre with abdominal pain and fever and it was like very general, like, I didn't really know what it was until I looked at her old discharge summary and I was like, oh, she had collections. Maybe they've come back. Um, and then lo and behold, we scanned her and they did. So, you know, it does happen. Um Yeah, and also just, just know what operation they've had. Like if you say to your registrar you're presenting, you're like, oh, they had a, a, an operation for bowel cancer and they've got a stoma but you don't know what operation they had or what they actually took out what stoma they've got, it just doesn't really help the, your registrar consultant very much. Um So just, yeah, know what operation they've had. Don't deep it into the op note, but um, it'll really help you. Um, and then the other medical problems, um this is really, really important actually, particularly as well. They sort of um functional status, uh their premorbid status. So surgeons get like a bit of a stereotype that they don't care about anything. If it's not a surgical problem, they only care about the abdomen. Um, nothing else. Um It's actually in medicine, obviously, we care about everything. Um, they care a lot about frailty scores and what they were doing at home do they have carers in ultimately a lot of medical patients? It doesn't really affect their management and you're gonna give them multiple based treatments anyway. In surgery, it basically changes your decision if you've got an 85 year old that's, um, coming with perforated diverticulitis and she's maybe, you know, lives on her own, does her own gardening takes on antihypertensive. There's a good chance you might take her to theater and do sort of lifesaving surgery and resect that, um, perforated bowel if she's a care home resident and she's got endstage heart failure, bad chest, they're probably going to manage just conservatively and it, if it doesn't work is they're going to palliate her. So it basically is life and death. So, having a good knowledge and sort of taking a good history in, particularly in older patients because everything in medicine, bad things obviously get more common as you get older, um, is getting a good grasp on what their other medical problems are and when you present as well and say, oh, yeah, this is a fit and well, 50 year old who runs marathons, um, rather than, you know, this is care in resident in her nineties. But we just focus your charter think because they're thinking, oh, can I take this person to theater, um, what treatment are they gonna be suitable for that sort of thing? Um, and also their medications. So, equally, um, your job sometimes optimizing them medically does kind of fall on the E one and the S um, your, a lot of patients for exam, a good example of this. So patients that, for example, have been vomiting for days, they're gonna have an AKI, um, I think like 30% of, uh, critically ill patients in hospital end up getting, uh, acute kidney injury. Um, so your consultant might see that and be like, oh, yeah, give fluids, but he's probably not going to go through all their list of medications. So all their nephrotoxic antihypertensives. So it's good. It would be good practice if you did this as an F one. when you're caring or when you're whoever's caring them, uh, uh, think about diabetes meds as well. Um, you might need to sort of optimize them, they might not have been able to eat and drink for a few days. Um, and if they're on insulin, this can, you know, they can end up getting hypos. Um, equally if they've got an infection, they might be high. Um, so think early if you need to put them on like a sliding scale or get a, a diabetes review. Um, critical meds, obviously in blood thinners. Um, in surgery, we see a lot of like p bleeds or like POSTOP bleeding, then just be aware if you're on blood thinners and stop them. Um, and then most surgical patients get VT prophylaxis. Um It will differ. What um what's your sort of trust guidelines? But um obviously if they're bleeding, don't give them VT prophylaxis. Um Don't forget taking the history particularly um in women, you'll get lots of women who present with lower abdominal pain, right? Elliott fossa pain, think it's appendicitis. So don't forget to ask about gyne stuff. Um I had a girl overnight, I think she had sort of lower abdominal pain slightly in the right Elliot fossa. Um But she had blood in her urine. Um So the ed, I was like, oh, I think she might, she might have kidney stones and she was like 18 years old. I was like, I think having kidney stones in an 18 year old is, is quite rare, but he was quite insistent that she needed like a CT scan and they actually took the history and she was on her period and that's why she had blood in her urine. Um And, you know, quite often we, um when I talk about right fo pain later. Um, we, we ultrasound most, um, women that come in with abdominal pain, um, and quite often they've got like, ruptured cysts and stuff like that. So it's good to know if they've got anything in their history. And then, um, obviously ask a little bit about testicular pain. I don't like, routinely examine everyone's testicles, but often I ask them if they've got any like swellings or pain. Um You can get a lot of referred pain, particularly in kidney stones and stuff like that. Um, that go down into your scrotum uh for a man and equally from scrotum up into the abdomen. So it's just worth asking and then do a good abdominal exam. Um Obviously everyone knows how to feel an abdomen, but the main things is just make sure they are lying flat, have their arms by their sides and usually I try and distract them when I'm examining them. So, um I'd usually talk, make someone talk with them because then you can actually list whether they're just reacting to you, um pressing their tummy or it proper guarding. Um And if I'm not sure I'll go over and try and palpate again. Um Yeah. Um I think that's everything for that side. So yeah. Um If you got any questions about any of that, just let me know like during or at the end and this bit is a little bit more upbeat. Um It looks like a lot. This is probably 80% I think of honestly what you'll see on a surgical, on call, it's very repetitive and we use the same formula for most things. Um, I'm not gonna deep into sort of like, um, all the types of bowel obstruction. Um, but I'll just give you a quick overview of like when you're clocking, um, sort of what investigations many imaging, most surgical patients that's imaging. So the best imaging to choose, um and sort of immediate management essentially, um that you'll do sort of whilst you're waiting for your registrar to come and review them. So, right in for pain, this is probably like one of the most common things you'll get referred, um, query appendicitis most of the time, it's not appendicitis. Um And actually I've found doing surgery now like three times. Um if it's like a band or perforate appendicitis, it's quite clear. But if it's sort of the early ones, um or it's not a very, very sort of convincing history, these can be some of the most difficult patients to sort of diagnose. Um And you see often like the register, I will bring the consultant to like feel a right if I of pain and feel if they really think it's appendicitis essentially. Um If it is appendicitis, which is the thing you're worried about. Um this is completely clinical diagnosis. Um You'll get uh you well textbook is that you'll get right elect pain migratory, right elects pain guarding and raising inflammatory markers. In reality, this isn't always the case. Um I think probably because this is quite common in younger patients, they often uh sort of can compensate quite a lot. So the abdomen might be relatively soft or the CRP might not be that bad. But then when you actually go to operate, it's, it's really, really inflamed, um which is what makes it difficult. Um We do usually when you're choosing imaging. So there's no imaging that's diagnostic. Most of the imaging we do is to rule out another cause. So it's easy to remember. I think um you might have been taught in med school. There's a bi modal distribution of appendicitis. It's in really young and sort of middle age. I've seen appendicitis in every age. So any right foss pain could be appendicitis. I think we had a 90 year old when I was in doing F one in Plymouth. Um They had appendicitis, they took it out as well laparoscopically in a 90 year old and then she got an ile S after, but she did recover. Um equally lots of Children get appendicitis. Um So the thing with um appendicitis is that um in a, in a young patient, it's likely to be appendicitis as you get older. Um It's more likely to be something a bit more suspicious. Um So that's why usually in an older patient, we would scan them by doing a CT scan in a younger patient. You'd usually do an ultrasound and this is for two reasons really just for ease and also for um uh sort of, you know, uh radiation exposure. Um and particularly young women, you would want to do an ultrasound of her abdomen and the transvaginal to look at her gyne organs. Um I think I just need to put a p plug in my computer and I'll be back. Sorry. Um Oh, sorry. Her again. Uh One second. Ok. Um Sorry about that. I didn't want it to die like a med scan. Um So yeah, the main thing to remember is any young patient do an ultrasound and then in an older patient you do a CT um if you didn't ct an older patient or of any patient, sort of over 50 you thought they had appen site and you went in operated and then you found they had diverticulitis or an obstructing scal tumor, you'd sort of be screwed. Um So that's the reason we scan them all. Um So, yeah, and then occasionally, um in a man they won't scan them, they'll just take them straight away because they don't have a lot of gyne gyne organs that could be causing them trouble um, in regards to antibiotics. So that's imaging. So if they're young ultrasound or CT antibiotics, if they're really, really sick or you're pretty convinced it's appendicitis, you'd start antibiotics in the people that are sort of you're not sure about. So the abdomen might be soft or they might not have had that symptoms for that long. The blood might, might not be that bad quite often. We send them home and bring them back and we don't give them antibiotics. The reason for this is, it sort of like, lets it develop. If it's very early, there's like, um, very low chance that it's going to perforate. Um, and it's sort of like lets the appendicitis um present itself so that they know for sure that you can do the operation. Um Yeah, and then just be aware of, of kids as well. Basically all kids get an ultrasound. Um Yeah, and then this basically the main things when you're examining them, I've never seen someone do so as an obturator sign. But I think this is to look for um if you've got um pelvic fluids. So, so a sign, I think if you've got retrocecal appendix, it will irritate your. So o as major. The ob sign is if you got pelvic fluid, it can um irritate the obturator muscles. But I've, I've never seen a lot of clinicians do this. Most people do things, which is when you palpate the left eyelid fosset and get right eye lip fos pain and then rebound tenderness. Obviously, when you take your hand off the fossa, um you get pain um in Children as well because essentially when you're examining them, you're looking for signs of peritonitis and in Children, sometimes they get them to, like, puff up their belly to, like, see if that irritates them, uh, or get them to cough. Uh, in the history. Sometimes people say about, like, going over bumps in the road or sort of movement, um, that makes it painful. Um, and if it's perforated and they're really sick, often you see sort of the person or the child, like, completely ST still in the bed because any movement will sort of, um, you know, irritate their peritoneum. Um, but then yeah, obviously wrist pain, that's the main thing you're worried about. There's lots of other things that, um, can cause wrist pain in a younger patient. It's probably going to be a uti or something. Um, not that serious in an older patient. It could be basically anything. Um, I've seen like bad gyne stuff, diverticulitis, cholecystitis, even in someone, um, kidney stones. So, just to be aware, uh, that's all. Um, then the next again, very, very common is right, upper quadrant pain, the main thing in surgery as well is just to think where is the pain and what is underneath it and that you kind of have your diagnosis. So, right, upper quadrant pain is gonna be something to do with the biliary system, probably the gallbladder. Um, the I wanted to mention this. So most things we'll get into a bit later. Most things in surgery. If you do a CT scan, it will show you the answers. Surgeons actually prefer ultrasound. I think it's more sensitive or it's very sensitive for gall stains and particularly imaging the bile duct. Um If they want more and more um sort of detailed imaging of the bile duct, they get an MCP, you don't need to worry too much about that when you're doing your initial assessment. But if it's right, upper quadrant pain, even if they're quite sick or they've got pancreatitis, usually they do an ultrasound first. The main thing is to look at the LFTs. Um, the reason being, so obviously this, um, this picture represents it quite well, but if the stones are in the gallbladder, um, usually the LFs are normal. Um, and this is like biliary colic or cholecystitis if they've got raised LS, particularly, um, sort of, uh obstructive picture. So, the ALP and the bili are raised, um, you'd be worried that there's stones in the bile duct. Um, and then they sort of sometimes the, er, er, CP to remove them. Um, the reason we worry about this particularly, we want to know if the stones in the bile duct is that makes them more at risk of getting, um, ascending cholangitis and patients really, really sick. Um, I've probably, I've seen some pancreatitis patients that, well, a lot of pancreatitis patients end up in ICU. Um, and they're often like the sort of sickest patients you get on the ward. Um, I did actually, I did it end in my F one. And we had a lady who's had a bile duct stone, she'd had an ERCP that failed. So firstly, the stone was retained in the bile duct. And then I think they thought that the ERCP has also triggered her to get pancreatitis. And in that four months, sort of F one placement, she was there for the same length of time on ICU and she was previously a fit and well, 40 year old woman. And then when I went to do urology at the beginning of F two and I was sort of covering the surgical ward. She, I then saw her again on the water. She spent sort of six months in hospital. Um all from Bardo Stone's cholangitis and pancreatitis. Um So it's like really, really serious. Um uh So yeah, cholecystitis, cholangitis treated with IV antibiotics, your normal like sepsis, six IV fluids, that sort of thing. Pancreatitis a bit more difficult. There's no like actual treatment for it. Um Specifically if they've obviously got an inflammed gall bladder, so you give antibiotics, but essentially you've just got to wait for the pancreas to get better on its own. Um And so you have to sort of just give supportive treatment. So make sure they have a strict clear balance. Give analgesia antiemetics. Quite often. Patients with pancreatitis get a um A PCA like patient control like a pain button just because the pain is so bad. Um, and then they're at risk. Um, I think a lot of text experts say they get s, but they, a lot of time they just end up getting chest infections because they're splinting their diaphragm, um, because they're not taking deep breaths in and, and they get really sick. Um, and then they end up going into sort of multiorgan failure, which is part of the reason why sometimes they end up on ICU. Um So, yeah, the salient points of this is just get um get ultrasound rather than CT for biliary disease. Um And then keep an eye on the LFs and either amine or lipase, whatever your trust uses for pancreatitis. Um So, abscess is very common. Um I didn't put a picture of this one but um the main things with an abscess is you want to know when you're getting a referral uh where the abscess is. Um Most hosts have an abscess pathway. Um So it will depend where the abscess is, what specialty takes it. So usually limbs, it's plastics or uh Ortho head and neck, obviously ent most of the time it's trunk, abdomen, groin, perianal, pilonidal. Um When I was an F one, we had a, I think I had a patient that had an abscess, sort of down below, like it was sort of in her groin, but it was like sort of engulfing her labia. So I got Gyne to see her. The Gyne Reg was like, really happy to like take her, take her and drain it. And then when the consultant, you, she said no, this is actually in the groin, you need to do it. And then general surgeons ended up doing it. Um Often breast abscesses as well are done by your sort of general surgical reg. Um So I know you're access pathway and often because these patients are fit and well, um we usually send them home if you see like an abscess that's come in the afternoon. Um You'd send them home, bring them back staff and then they do the first thing on the C pod list. So it's like a very quick 10 minute operation and they can have the operation done and go straight home. They don't need to stay in. Um So it stops and sort of waiting around all day, waiting for there to be spaced. Obviously, if they're septic, um you got really raise inflammatory markers, decompensating, particularly the perianal abscesses, they can get quite unwell, then you wanna admit them for IV antibiotics. Um increasing some of the breast abscesses, they can be in quite a lot of pain. Um and not really coping at home. Um And then when you see an abscess, it's um sort of good practice if you sort of draw. Um Sometimes if there's an area of cellulitis around it, you just draw around it. Um It marks it for theater and it, you can see if the area of cellulitis is spreading. Um, very rarely, abscesses can be drained on the ward under local. But, um, this actually tends to be very, very painful. Um, a lot of abscesses go a lot deeper than you think. Um, particularly if they're on their trunk or their back, um, they can bleed a lot as well because it's quite vascular. Obviously the, the deep you go down. Um, and then people end up sort of being in more pain than they were sort of. So, um, but if it's a smaller abscess, your registrar might let you sort of drain it on the ward. Pure bleeds again. I didn't really want a picture of this one, but, um, the main thing in APR bleed. So, so 80% of pr bleeds will settle on their own. We just give supportive therapy. You want to ascertain basically, if they're stable or not. So you wanna know their BP, heart rate and their HB, if their HP is dropping, you need to transfuse them. If they're, um, hemo un stable, you need to transfuse them. Um, and you also, it sort of makes the investigations, you're gonna do a bit more urgent. Um, if they've sort of had a bleed at home or they might have another bleed in the hospital, they might still be bleeding. But the HP and BP and stuff is fine most of the time we just, uh, stop there, um, anticoagulants if they're on them let them eat and drink and just wait for the bleeding to stop and then just monitor them. Um, and most of the time it does stop and then sometimes we restart the whatever and then it bleeds again. Um, and then the ones that stop, um, sort of managed with conservative management can have a lot of, um, investigations done as an outpatient. Um, particularly with, um, I was saying earlier about looking at previous investigations, previous admissions, a lot of people with P bleed have pr bled before and they'll know why. So like they might have really bad hemorrhoids or, you know, they might have had a colonoscopy. Um that's found they've got diverticular disease or angiodysplasia. And so that again, will kind of give you the answers. Um And then, yeah, when you're resuscitating, um usually we resuscitate the HP is less than 70 sometimes less than 80 if they've got um sort of heart failure. Um But you can consider things like TX A. Um you can give them vitamin K for most people, um even if they're not on Warfarin and then if they're on a Doac or equally, if they're on Warfarin and they've got very high inr, you can give things like be plaque, which is like um FFP and pro um prothrombin complex. Um But yeah, just make sure that just you need to as in if they're stable or not and then resuscitate if you need to. Um And then pr them as well. Everyone should get pr and the reason being is you want to know if they're still bleeding and also ascertain whether this is pr blood or upper G I blood. If you've not ever seen Melena, essentially Melena is black and it doesn't really resemble anything that looks like blood. You and everyone says you'll know when you see it. Um, it, it just does look nothing like blood, um, bowel obstruction. Um, so I'm not going to go through all the causes of bowel obstruction because there's lots, you can get small bowel obstruction, large bowel volvulus. Um, all these patients essentially will end up getting a CT scan because you need to know the level of the obstruction. Um, and things like if it's a closed loop obstruction. So the ilyce valve is competent, um, if there's signs of perforation, um, if it's small or large bowel, so they'll all end up getting a scan anyway. But, um, as someone that's cla, um, just you want to do sort of d drip and suck method. So, put in an NG tube also catheterize them because you need to restrict the balance in and out. Um, because they're not going to be eating and drinking once they've got an NG tube in. Um, yeah, that's all you need to know, like immediate management of bowel obstruction. Um, and again, lots of patients, particularly if they've had like a surgery in the past, they might have commonly have adhesions. Um, and they'll, uh sort of intermittently come in with sort of sub acute adhesional bowel obstruction. So, if you look at their old discharge summaries or they might know that they've come in previously and know their symptoms and this can help point you in the right direction. Um, yeah, most patients have with conservative management as well, um, particularly the ones with adhesions, hernias as well. Um, the main things with hernias is just know where the hernia is. Um And so you can sort of describe it and then also I didn't really understand when I was, even when I started, um, f two, when I started ct how you describe a hernia, lots of people have hernias, they pop in and out, they're fine. Lots of people have hernias that are um irreducible, they pop out, that's also fine. Um This is what we would call an incarcerated hernia. So, um, essentially the hernia is trapped, can't be pushed back into the abdominal wall. Um And usually people are fine with that as long as it doesn't cause them pain. If it's very symptomatic, they'll, they might need a, a surgery. If it's strangulated, this will mean that it's irreducible, but there's, um, the bowel wall essentially is squeezing on the vascular supply. This is actually a surgical emergency. If you leave this, I think more than like six hours, the bowel will become ischemic, it'll perforate, it'll become septic. Um, it'll be really, really bad. Um So typically, like with hernias, and if you're worried, it's obstructed or strangulated. If you look at the lactate, that can give you a bit of um information about whether it's ischemic. Um and then obstructed hernias. So these can become strangulated, they might not be strangulated. Um But this is when the actual bowel lumen is compressed but not the vascular supply, vascular supply. So they'll present with a bowel obstruction. Um, so you can just do again, your drip and suck method, um, for managing that. Um, and sometimes these settle on their own. They might warrant surgery on this admission, but it won't need to go that same day. Um, and typically in the history, um, because obviously people have hernias for years and it doesn't bother them, they'll have like an acute change of like color, severe pain, obstructive symptoms. Uh, it was, might have suddenly popped out and not be able to pop back in. Um, yeah, and then again, so most of these patients end up having a CT. Um, because if you miss a strangulated hernia, even if you, it doesn't look that bad, but you miss a strangulated hernia, um, it's sort of a disaster. Um, and a lot of things we do in, in the NHS, you realize it's sort of defensive, defensive medicine. Um, and yeah, you can see on these scans sort of quite clearly where they've got herniated tissue. Um, so acute abdomen, obviously most of the things we've already talked about about is sort of an acute abdomen. But um, these are patients that have got sort of some sort of abdominal catastrophe, they'll be very, very sick, likely Peric, maybe septic. Um And you would hope these patients would sort of be in a higher level of dependency like ed recess. Um, and often the registrar to see these straight away, um, it'd be unlikely to be assessing them on your own as an F one. Um But the ro might take you with them just sort of uh experience or they might want you to help sort of prescribe their meds, prescribe their fluids. Um There's some score um If you, if they've got sort of like something really, really bad, like a perforation, um you know, they might have some scoring systems. I want you to help them calculate and sort of contact the family, whether they want to because if they're really elderly, like I was saying earlier, you have to decide sort of what, whether you're going to take them to theater urgently or sort of sit on it and try conservative management first. Um But yeah, these always end up getting an urgency t and then you'd just be managing, managing them as you're like sort of uh normal sepsis sex. Um But you'd hope these people would be sort of, or D and Ed, they wouldn't sort of just be in the waiting room chilling. Um and then I wanted to just see one slide, um, about diverticulitis because I wasn't taught probably anything about this. I think I vaguely knew what it was from med school, wasn't taught anything about it. And when you do a surgical on call, basically every patient will have it. Um, most elderly patients, um, lots of patients have it, but it's asymptomatic, you'll see it sort of incidentally on scans, incidentally on colonoscopies. Um, But often if it's like an abdominal sort of disaster, like a perforation, um it's usually from diverticulitis. Um And there's sort of four classifications, you don't need to memorize classifications or even know them when you're clocking them. If you're worried, they've got diverticulitis, which would generally be an older patient with inflammatory markers and sort of their abdominal pain tends to be left eye also because that's where the sigmoid colon is, but they can have like a floppy colon or it can be referred. Um But any sort of generalized pain in an elderly, in an elderly patient with ra in markers, you'd be scanning cream diverticulitis. Um I just wanted to sort of explain the different types because it can make a bit more sense when you're like getting the reports. Um because they're kind of all perforated or they have some sort of abscess. And I was like, well, why didn't you operate on all of them? You don't have to on, on every single one. So the first one, which is a, which is, um, you've got an abscess form. So normal, uncomplicated diverticulitis is just when the out pouchings are inflamed. Um, these usually are treated with antibiotics if they're, well, not in too much pain and the inflammatory markers aren't too bad. Occasionally, a registrar might stop the antibiotics, but you don't need to worry about that when you're initially caring. Um, if it, these are sort of the four complicated types. So the first one is that they've got an abscess, but it's sort of attached to the diverticula. Um, usually this can be managed with just antibiotics or they can put in like an IR drain, which is like a CT guided drain. They can put in to drain the abscess. Um, certainly if you were going to get, put a cut and drain like a, a surface abscess, um, the second stage is, again, it's a walled off abscess, but it's a bit bigger. So it might be sitting in the pelvis or sitting. Um, retroperitoneal stage three is actually a perforated abscess and there'll be pus in the pelvis. These I think can still be managed conservatively. We had a patient at the weekend who, um, had a really bad perforated abscess. They put a drain in which was draining, but he was really, really septic. He'd gone into Phos AF and we were sort of persisting with it. But like, um, I think on the wall done on Monday morning, his like heart rate was 100 and 60. He looked really, really sick, so he ended up going for surgery. Um, but stage four is when you've actually got the bowel mis perforated. Um, and you've got fecal peritonitis and this is pretty much unsurvivable if, um, if you don't take them for a heart men's, which is like an emergency procedure to take out the sigmoid colon. Um, so I just wanted to mention this. So is it makes a bit more sense when you're seeing these patients when you're on call? Um because you'll get the CT report back and you're like, oh, they've got perfect diverticulitis. You're like, why aren't you taking them straight to theater? But some of it obviously can be managed conservatively. And then I've probably said this to every side, but nons specific abdominal pain is probably the most common thing you're going to see when you're on call. Um And it can be very difficult to manage, very difficult to diagnose. Um, a lot of your wrist pains we mentioned earlier that have normal blood to normal scans. Um They'll end up, you know, we don't think they've got pentiti, they've sort of got nonspecific abdominal pain. Um It's essentially just branches, anything that we can't find a cause for. Um it's really, it's really important when you sort of are discharging these patients because often the reads will get the results and they're like, oh, I need to go to the theater. Now, can you send them home so often it falls on the f one to sort of, you know, explain everything and discharge them. You have to be like, really, really reassuring and explain to them that like their bloods are normal, um, scans are normal. So anything serious would have been picked up and they don't need a surgery and most of the time patients, they don't want a surgery, they don't wanna hang about in the hospital. They want to sort of get back to their everyday lives and they're quite grateful for it. Very rare. Occasionally people can get a bit, um, and usually out of fear they can get a bit skeptical or they can get, oh, well, maybe you're missing something you've got really, really bad pain or think, sort of get the gist that you think that you're wasting their time. Um, so you have to just be really, really reassuring and explain as well. Most of the pain we see is nonspecified. Um, I think my, one of my registrars that like a third of the pain we'll see on call is, um, we won't find a cause, a third will find a cause we can treat medically and then a third will need surgery. So it is relatively common. Um, occasionally you can get sort of like chronic pelvic pain, chronic abdominal pain and not to be sort of bias. It, it often tends to be in like younger women of childbearing age. Um, and there probably is something GNI that either has not been discovered or, you know, we don't know about or something rel related to menstruation. Um, but it usually goes away on its own. Um, if it doesn't go away on its own and they've got chronic abdominal pain, it can be a bit more difficult to manage. Um, but you can always sort of validate that they've got pain. So say, um, you know, obviously say, you know, you understand they're in pain and then offer them, they can go home with like some anti sickness or some codeine and just to sort of safety net them and often this will make them feel a bit better that like they're not gonna go home and be left with nothing if the pain comes back, um, and safety net them as well, um, and document what you've safety netted. Um It just in case they come back. Um, obviously most of the time pain that's come on over a period of days will go away over a period of days if it's been there for months and it's, you know, not just come overnight, it's probably not going to just disappear the next day. Um, but I have seen a couple of times, um, sort of, it tends to be younger women, uh get sent home with like appendicitis but was normal and then come back and they've actually perforated. Um, and I remember one when I was an F two. She had come back a week later with worsening abdominal pain had been sent home. Um, and she probably tried to convert to open and she was sort of like young woman now got a big scar. She ended up staying in hospital for like, one or two weeks after, like, really struggling with pain. When usually after an appendicitis, she'd go home the same day or the next morning. Um, we also had a boy at the weekend. So I think on Thursday he'd come in after eating like a dodgy burger and he, he had just thought that he'd had gastroenteritis. He come back on the Sunday. Um, and he perforated, it was really, really, um, protonic. And so it's important that you safety net. Um, and like my old trust as well, I think you could give them like an open access for like 48 72 hours to come back if their pain got worse. Um, which is just like, makes them feel a bit more reassured. So they don't have to go back through their GP and sit for 12 hours in A&E. Um, but it can, sometimes people can get a bit upset when you tell them that there's nothing wrong but they've still got pain. Uh, but most people it's fine. Um, I was just gonna mention that's all the sort of like, that's basically all the clinical stuff I was gonna cover. Um, and I think that covers most things you're gonna see. Um, as I mentioned earlier, it's f one you might be doing ward cover when you're on call. Um, my first shifts as a new f one doctor were doing nights. Um, and so like from midnight I was covering the wards. Um, and again, it's very different. If you're sort of doing a normal ward day, there's like maybe a team of you and you've got the consultant or you've got registered contact or consultant. See one in the morning, you're sort of out on your own, seeing a deteriorating patient. Um making a plan, it can be quite daunting. Um the main things just to be aware of. So know what specialties you're covering, as I mentioned earlier. Um Even if you're say a upper gif one, you might be covering all of general surgery and urology and vascular quite, quite commonly depending what specialties you have on site at your trust and know what wards you're covering. Um because some wards as well will have like medical outliers or some surgical patients might be on a G you ward. It's not uncommon. Um So just make sure when the nurses um sort of give you give you a referral that you like. Oh yeah, this isn't like an Ortho patient or something. Um know how to receive task and jobs. So make sure you've got like the ward cover bleep, usually there'll be a designated bleep. Um There might be an online task board. Um, as I mentioned earlier in my old, um, when I did F one F two we had a sort of after hours you got like this iphone thing where jobs came through. Um, just so, you know, you're not missing anything if they're escalating someone that's, like, very, very sick. Um, it seems obvious but always prioritize the deteriorating patient reviews. Um, it's actually sounds obvious but it's really, really, um, when you've got like, 10 jobs and then you think, oh, these five jobs I could quickly do them remotely, like from the mass, I'll quickly do them now or I'll just bosh these three cannula. It take me any time at all. A sick patient. You can take you like, 45 minutes an hour. You've got to use your head, you've got to, you know, contact special other doctors. Um, you might know what's going on. It can be really, really scary. Um, so, but yeah, always prioritize them, even if the nurses keep hounding you to prescribe, you know, anti sickness for someone that's completely well or do a discharge summary or speak to the fa the relatives always prioritize the sick patients. Um, and I'm not gonna go through, it doesn't, I don't really have time in the scope of this talk to go through management of a sick patient. But if you take one takeaway, um, basically everything can be, I think most things can be solved by an A two E or receptor six. if you're not sure what's going on, just do an A two E, if the patient's sick just do an A two E. Um, you sort of learn it in med school and you're like, oh, surely people don't do this like ABC D thing. It's like a bit of a gimmick. But honestly, like everyone, you see, everyone that gets caught in an D gets an A two E assessment when I worked on I the ward round was an A two E. It like you can't really miss anything and it all does focus you if you're tired in the middle of the night, you I've never met this patient. If you go through, you're like fine airway is fine b the chest that's breathing, the chest sounds fine and then you have circulation like, oh, circulation is a bit off what's going on, et cetera, et cetera or maybe circulation is fine. You like, no, actually, maybe it's an abdomen thing. Um And then again, most things you're going to see is going to be like a POSTOP pyrexia, postop, shortness of breath, POSTOP bleed, potentially, but big bleeds will be picked up. Um In recovery, we would hope um maybe, you know, like a full uh fast af uh but yeah, most things, it particularly surgery is going to be infection related. So just remember to culture everything. Um culture, urine drains wounds if you get wounds. Um get a chest x-ray blood cultures and then just start them on broad spectrum antibiotics. Most of the time it can be tazo unless your chest has really whack guidelines and that will, like, keep them pretty much stable. Um, and remember as well, like, even if you've seen a patient and like, they've, um, got an antic leak or, um, you know, they've got, you know, something that needs to go back to theater. If you're overnight, they're pro if you're working overnight, they're fine. They're probably not going to go to theater straight away until the morning. So, doing your basic management is like probably the most important thing you can do. Um, obviously escalate to a senior early if you're worried. Um, even if they're like, your reg might be asleep. If you're worried, like, ate earlier, they'd rather you wake them up at like 11 pm than wake up at three in the morning. Um, and the patients even more sick, like, you know, even more deteriorated. And so get, um, senior senior help early. Um, equally, I have seen some of my eon colleagues. They sort of, I'll be asked to see a patient that's using like a seven. They go and look at them and they look awful and they just panic and they don't even know where to start and then they all sort of run out of the room and, like, go and grab someone else at their regular sh to come with them, it's not out like it's, that's not unreasonable. It's safe. Obviously, if you get there and like, um, they look like they're perio rest or they've got Stridor or something, you need to just put out like a cardio or me call. But if you sort of, if the patient is develop, you know, ok. And you can at least do an A two E, you can quite quickly, even if you do a quick five minute A two E, you can ascertain where the main problem is, is it their chest? Is it their abdomen? Is there blood all over the floor? Is there, you know, is their BP? Um you know, is it their gcs? So, you know, you can, when you do go like run and get your registrar, you can sort of basically say like what's going on and that can help them as well. Um And then obviously your sho is your friend, I think when you're doing will cover. Um particularly I found on F one when I was working with an S that was like a new F two and they just finished being an F one. So actually it was like more relatable. They would be like, really happy to help you. Um They'd know what it's like doing more cover and basically, when you're on an F two, I found you're just kind of like a slightly more confident F one, you're not making like big decisions. No, one expects a lot of you. Um, but you sort of know what's, what's serious. What's not, you, you're used to, you've done a few more, a two weeks. You're a bit more confident in your sort of plans. Um, so, yeah, I, I, yeah, always like contact your sh if you need help or even if you, like, have small things, you think it's not big enough to ask a red, you can just ask your sh and they wouldn't mind. Um So final comments unless you have any questions. Um Yeah, obviously don't make the mistakes I've made as F one or F two, stay calm and organized. Um If you're having like a really, really awful shift, um and you haven't had a lunch break if you like take 10 minutes to like just sort out your jobs list, actually make a list of what's back, what's not go through the list, see which patients need parking, make a list of those this 10 minutes or honestly, like save you like three hours of confusion and more disorganization. And then when you say your registrar just come back from theater or you get another refer to come and help you. Um Then you can say to them quite quickly like, oh, these patients need caring. Would you mind in the muscle out the post a jobs? Um Yeah, and I have one colleagues to help as well. I did mention that earlier, but when I worked on colorectal if like, one of our team was on call and they're particularly busy and it was quite in the water, one of us would usually get help, which is quite nice if you've got a lot of jobs, um, communicate well with your team. Try, get the phone number of your sh and your registrar and just know where they are all the time and how it's best to contact them. Um, and if they are gonna go to the theater, just say like, you know, how long do you think it's going to be? Is it, you know, quick appendix gonna be 45 minutes or is it going to be a laparotomy? That's like four hours. Um, because then they might think like, oh yeah, maybe I need to get another registrar to help you or another senior s prioritize the sickest patients, um, remember to eat, um, handover. So that's part of like, um keeping the list up to date and then hand over to your night colleagues if there is anything you've missed, um, or scans, et cetera just to be safe, make sure you, you know what you need to hand over. Um And also every remember every bad shift goes to an end, it comes to an end. So, you know, it's just 12 hours of your life. Um I've done this many times. I'm like, oh, I've just got to get through the next three hours and I'll be at home having dinner and be in bed. Um, and sometimes, then you just go to sleep and then have to come in back the next day quite early. But every hour shift comes to an end, um, when you've had a few bad shifts and I'm not saying your surgical calls will be bad. They shouldn't be bad. Um, they shouldn't be unsafe at all. You shouldn't feel unsupported. Um, but when you've had like a few busy shifts, you'll like, get a bit used to it and you get a bit more confident. Um, I remember surgery is very repetitive if in doubt, um, CT scan. Yeah, I think that's everything actually, unless anyone had any questions. Oh, great. Thank you very much sharing. So I might, I, I thought my computer was going to die so I like panicked. But, um, no, that's completely good. Thank you. Um, thank you. That was really interesting. I think everyone probably learned a lot from that. I know I did, I think really good insight into kind of the basic things you're going to see and how you might want to manage it, which is quite a daunting prospect for most people. I think going into F one. But knowing, I think you sharing some of the experiences that maybe what didn't go so well and how you came over them was really helpful as well. Um, and I definitely echo like the Sh Os and the registrars are just really there to help you and they might fight your head off sometimes. But on the whole, they're really good. Yeah, I think you have to remember like, um your child has like, done like 20 like hundreds of on calls. So to them it's like sort of part and parcel like they're used to it. Um Whereas in F one, like, I remember being F one, like, I literally didn't know anything. Um I graduated like in the middle of COVID. Um So my, like, funny, it was pretty limited. Um So yeah, I think sometimes it can come across like they don't really might be a bit short, but I think it's because they don't remember it was so long ago. Um But they're never going to like, you know, not gonna be horrible and that's why it's really good having SJ there with you as well. Um So please can everyone in the audience fill in the feedback forms. It's really useful for both us and Louise and guides future sessions. We do have some more coming up. They should be weekly. Now, we've got wellbeing cardio respiratory, um general surgery and discharges coming up in the near future. So please check out Twitter and Instagram where we'll be posting them. We've got a few thank yous coming through Louise. Um I think that's really useful. I think you've covered most of the key questions. So if no one has any other questions, I'll let you all get off to the rest of your evening. Yeah. Thanks a lot for inviting me as well to getting bad experiences. It was really great to have and it's really, really fun. Actually, I really enjoyed my calls. I think that's a great note to end on. So it's really fun guys along with all the learning. Thanks very much. Good evening. Take care. Bye.