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moment. Oh, too late. I've already pressed the button. Hello, everyone. My name's Phillip A. I'm the chair of the Yorkshire Foundation Surgical Society. We'll just wait for a few more people to join us and we'll. Then we'll start. Hello again, everybody. My name is Philippa. I'm the chair of the Yorkshire Foundations Surgical Society. We are predominately based in Yorkshire. But do teaching events roughly ram once a month, aiming to try to get more people interested and into surgery as a career. Um, this evening we've got to fantastic speakers Chloe, who is an academic ST one trainee, and Adam, who is a Post Corps trainee fellow. Um, we're gonna be focusing particularly the clinical in the management, the clinical stations as part for the course surgical training interviews today. If you've got any questions throughout, um, just pop it in the chat, which will be monitoring. We can pass them onto the speakers, and we will be asking people to be interactive during. So if you'd like to volunteer for how to be one of the test patient's, just pop it in. Okay. All right. So, first, if I'd like to introduce miscarry Kwan, Chloe or mute. Hi. Hi, everyone. I'm Chloe. I'm a s t one, um, in Bhaskar surgery in elite. Um, I just did my CSC interviews last year, so hopefully not too much would have changed. Um, just to give everyone a brief overview, Um, as you guys might really know from last week, that's a presentation. That's the management station. And then they usually are two clinical stations. Traditionally, one of them will be a trauma question, which follows the A TLS principal. And the second clinical station will be like a POSTOP patien or unwell surgical patient that needs managing through the crisp protocol. So I'll be focusing a little bit on the A T l s, um, section. And then Adam, who is very is excellent will give you, um, some of his part about the management of the unwell surgical patient's. Any questions? Just type in the chat. And I'm sure me and Adam will Hopefully, we'll be able to answer them. Um, so just a few key points. Um, overall, there's just a few things they're looking for, which is Are you sensible? Are you safe? And they're looking for someone who's quite organized, and there's a structure to we're talking about. So they want someone who follows, like a structure rather than sort of random points all over the place. And me and Adam will give you a little bit of information about the what sort of structure to use afterwards. Um, be precise. Normally, they allocate five minutes to each clinical question that includes the question being flesh on the screen, you reading the question, you giving your opening speech and then the examiners. Uh, well, I don't know how many questions they do, but they they have a list of questions which they go through so normally, after you ask each question, just keep going and going and going until the list of questions is finished. It doesn't matter if you don't get through all of the questions, but you should give them a chance to at least ask you some of the questions. And so you just need to sort of figure out a good time balance and then, as I mentioned earlier, Normally it's one trauma question for by one unwell surgical patient. So how does how the clinical station start out if they will show you a question and then just say when you're ready. Just start. So I normally would take off about half a minute just to read through. Just plan on what I want to say. And I have this opening paragraph on the screen, which is pretty much the standard for what I will say in every question, obviously plus minus some of the bits. And I don't know why we had a chat, and I think also pretty similar. So you can pretty much use this as an inspiration. But they should cover most of the points that you need to mention the starting paragraph. So the first thing that you should probably always start off with is to list the thing that you worry the most about. This will show the Examiner they're thinking about the worst possible case scenario. And that's one of the key point that they're looking for. Um, so, for example, um, if someone comes in following a fall and you say something about the legs being shot externally rotated, you can say in this scenario I'll be most worried about neck of femur fracture just to show them your catching the point of the question. And then you say I will assess and simultaneously resuscitate and stabilize the patient through an eight e examination. So you want to do assessment, mentioning that you have resuscitated the patient and you're stabilizing them because that's the key point. So the next part you say, is as per the A TLS protocol and in the unwell station, you say, as per the Chris Protocol. So that's quite important because they want to know that you are aware of the A. T. L s protocol. After that, I'll say, Following that, I'll take a focus history examination. And if you think it's an emergency, if there's something massive going on, you can always say I'll contact the registrar whilst arranging my initial investigations because one thing that people always forget to mention is to escalate the case. Your seniors. So you're not gonna be taking the patient to theater. You're not gonna be operating patient. So as long as you suspect that it's a surgical emergency, you need to escalate to your registrar. So following that will be your A two e assessment. And as you can see the screen, I'm not going to read it out to you, but that's pretty much what you say. The main thing about the A T. L s station and compared to the unwell patient station is that you need to remember to mention c spine mobilization. So that's why one point that people always forget to mention in the A. T. L s trauma section and you need to mention it, and it sort of falls fractures. Even if they come in with a chest injury, abdominal injury. You need to make sure that the C spine is protected and immobilized. And then do the airways asthma. What, you're looking at c spine. So I would as you can see the screen, I probably will mention a few things just to show that you know what you're thinking about. So rather than just saying, for example, I would do some bloods. I'll just say I would do blood and I'll check for food. Blood can't use Aeneas coating blood gas. Just, you know, say it. Show them you You're thinking about it impulsive thing as well Group and safe and cross match and trauma, because if these patient's need operation, they will need a group and safe Um and then the last part is in a trauma station or an injury station, you need to mention the last part. E. I will carefully examine the rest of the body, especially the abdomen and the lower limbs. So that forms the whole 80 are saying. And that's probably what will be different from the examining unwell patient on the world, because you want to rule out any other injuries that you might have missed. Okay, so following that you pause, you give them a chance to ask you the questions, so I don't You know, I've read that for 1 to 2 minutes, and I'll pause. So normally there are fours or 4 to 5 standard questions that you want them to ask you in addition to any other additional questions. So one question that, uh, these two questions always come out. So what would you ask for in your focus history? So something that uses sample, which is allergies. Medications, including anticoagulants, if they need surgery. Past medical history, past surgical history very important. When was the last time they ate or drank? Once again, If you need to go for surgery and do a brief sort of history and then the second question, I ask is what you're looking for your examination. So normally I'll follow the paper format, which is a position the patient look pulpit, because Oscar take and depending on what the cases are, safer things I'm looking out for. So, for example, once again going back to the example, if someone's coming in with, say, um, a trauma to the lower limb, you will say, I'll be looking to make sure see if there's any abnormal positioning of the legs, making sure it's not shortened. Um, I'll do a neurovascular examination. Make sure the neurovascular in tech So you just want to mention the things that you're looking for in relation to the case rather than something generic. Um, in some sort of traumas, like spinal traumas, abdominal traumas, lower limb traumas, something that's often focusing about is a D. I. E. Examination to check for, um, called equina. And it does any sort of crush injuries limit injuries. You always want to make sure and head injuries. You always want to make sure you do a neuro vascular, vascular or neurovascular assessment. So these are the things that you score points for that people always forget about. So the next sort of standard questions will be What? Your differential diagnosis? Um, I'll say 3 to 4 differentials will be enough. You don't want too many, but you want to show them you're thinking about all the possible different, um, differential diagnosis. And then the next question normally will be what investigations? Which you do next? Um, I personally always start with bedside investigations and then bloods and then imaging. Um, in bedside investigations are almost always, say e c g and A V B G for lactate and any clinical stations because there will always be relevant. It's probably some patient that you're going to bring back to theater, so you need an E. C. G and in an unwell patient will always want to lactate. So I will always say E c g and A V B G. And then the last question, which is potentially quite the most important question, is they will ask, What is your immediate management of the patient? Um, the method I remember is I always sort of mentioned the four A s, which is I'll give them energies here according to the W h o pain ladder. Um, if you need antibiotics I'll give them antibiotics. So that's probably more of your unwell, sick patient's or open fractures. Septic Patient's, um, anti thrombotic. It just means vte prophylaxis. It's just to fit in the four days, um so vte pre flexes and antiemetics. Sometimes you mentioned some point like the patient's on. Well, they're vomiting and feeling poorly so that you can say, because the patient's feeling well, I'll shoot them symptomatically and give them some anti emetics. So those are some of the medications I will give an emergency setting, and then that's the point. We decide. Do they need conservative management, or do they need to go back to theater? And do they need something active doing? And if something active needs doing, you would say, I'm going to keep them new by mouth for them on IV fluids. I will consent them, and then most people would then go on to say up in for my registrar. But to to get bonus points, you can say I'm going to speak to my registrar, the theater acute tater coordinator and the initiatives because the initiatives we need to assess the patient for the operation to go ahead and you need to sort of sort of lets take a manager, know that cases coming. So those are the bonus points and then to just to wrap it up. Also for sort of bonus points, you can say I would document, um, speak to the patient to make sure they're aware of what's happening and inform the next of kin. Um, the A T. L s trauma section is admittedly very vague. Um, there are lots of stations that could potentially come out, and I'm not gonna be everything out to you and explain all the possible things that can come out. But they're mainly categorize, so you can have burns. Um, so this is probably one of the more rock stations which people don't do really well in. So some things that you might want to do a bit reading up on is burns the rules of nine, which is I'm sure some of you might have heard of it to calculate how much of the bodies burned and therefore whether they need to go to specialist management center or not, and how to prescribe fluids and bones, um, head injuries. So someone had to fall downstairs, and then you probably need to know a little bit about the different types of head injuries. Extradural, subdural, subarachnoid, blah, blah, blah, uh, chest injuries. Someone's having a car accident and they come in and they've got massive bruise on your chest. Abdominal trauma. Someone's been stabbed. Um, pelvic injury. So typical one would be someone so fallen off a horse or another lady has fallen down a flight of stairs and they think they've broken the hip. And another common one, that's all falls between the HDLs clinical station and the crisp station is compartment syndrome, which can occur either POSTOP or it can be post crush injury and post trauma. So you need to know your six piece in the compartment syndrome really well, and you need to be able to recite the six piece. So linking to all these potential stations and there are some questions they can come out, they will ask you specifically to decisions. So, for example, if abdominal injury or chest injury comes up and the patient's bleeding, they might ask you, How do you classify shock? So you need to know about the classification of shock. You need to know a little bit about the classification of hip fractures and one that is a little bit road that people have said have come out in the past. But I don't think it's come up for a few years, but I think it's better to know than not to know. Just in case it comes out is emergency tracheostomy management. So what happens if someone has a tracheostomy and it's fallen out? What do you do in the world? Um, so there's a flow chart. Google it emergency track, calcium in management. Have a brief look through it. And as long as you know vaguely what to do, you should be fine. So I've got two stations. The first one is sort of covering chest injury, which we'll just talk through review sort of potential questions. And then I've got another station, which we can run it as a full sort of mock interview. So if anyone wants to do the mock station, just, uh, let me know. Okay, Um, so this is the Round three station. So, for example, you are the CT one covering surgical specialties at a district hospital. You have been called to see someone who's fallen down 10 m down the side of rock face. So a and the scan. His head is normal. But now he's suddenly developed left sided chest pain so a chest actually was performed but not been reviewed. How will you proceed? So for this one, let's just use of questions rather than run through. So anyone in the chat or everyone do you wanna write about some of the potential differential diagnosis you're thinking of and what you're worried about? So I'll say. Like I said earlier, 3 to 4 would be good. So if you guys wanna type potentially four diagnosis that you're worried about and you'll be self running through your head, No. That's why we can just talk through it. Brilliant. Thank you. Yes. Tension Imitrex. Any others? Hey, Imitrex. Lovely. So bearing in mind that chest injuries probably the most common questions to come out, and it came out for me last year. Fractured ribs, perfect. Feel chest. Perfect. Okay, so you need to know the top. You need to know what it's known as the little six. So these are the six chest injuries that you need to be worried about, and these are life threatening, so you need to know this six by heart. So in a station, if it comes with a chest trauma, you need to mention all of this as a differentials because all of these are life threatening. So you have a ways of every obstruction tension rhetorics. Well, every obstruction. Not really, but tension. Pneumothorax open new meth, oryx, massive Hemet, Oryx, Phil Chess and cardiac campana. So don't forget cardiac campana. That's really important. That's the one that most people forget about. Uh, so now if you wait the questions that go, you can either ask you and they can give you examination. Findings are shown, or they can ask you what would you find our examination? So if they say oh, on examination, the trachea's debated to the right. There's bruising and tenderness, reduced air entry. What do you think that might happen? So they might be pointing you towards the differential diagnosis. So how will answer This is said this would be consistent with the left tension normal to Rx. And then I'll go on to say I'll perform sort of needle decompression with a logical cannula in the second intercostal space. Although the guidelines the A TLS has changed two years ago. Three potentially and some people do in the fifth intercostal space. Now, um, in the mid, uh, mid axillary line, Um, and then you escalate the patient, and then they might follow up with a different question. So say this patient doesn't have a neuro Terex, and they only have a rib fracture. What would you do? So in that case, you will once again decide whether they need conservative or surgical intervention. So, in this case, as a New York state rib fracture. So you most route fractures are managed conservatively to begin with, and this is a condition that's managed quite poorly. You need to You need to make sure they have really good energies here because it's not the rib fracture that kills them. It's a complication that kills them. So if you're not taking deep breaths, they're not moving to get DVTs pas. They get pneumonia. That's what kills them. So once again, you mentioned analgesia. You mentioned V D prophylaxis, and then we'll talk a bit about conservative management of encouraging the patient to take deep breaths, chest physios, monitoring and, as I mentioned earlier, discussing the patient and discussing the notes and then you want to talk a bit about interventions. So if the patient becomes more unstable, then I may need a CT scan to rule out pulmonary contusions. And if they become unwell, I'll speak to my register. So this is just a bit of a run through about chess injuries. Um, so I've got a mark station next. It would be very chill. Does anyone want to try to do it? It'll be really quick. We can do like, five minutes. You can do a little talk, and then there'll be, like, three questions. Does anyone want it at all? It would be a very good chance to practice doing it. If no one wants to, I can just walk you through it. But it'll be. It'll be a bit boring, but no last call. All right, James. Amazing, James. We'll just invite you to the stage so you should be able to turn your microphone on. And are you alright to turn your microphone on, James? Would you be more happy typing the answers into the box, I think. Hi, James. Thank you very much. I think it would probably be quite nice if you speak on a microphone because you can then try to see, because five minutes is not long at all. And you just sort of need to so of get used to the timing. So we'll so we'll do five minutes plus manners. It's really chill. Don't worry. I'll put a question on take whatever time you want to read it, and then just start whenever you want, and then I'll start the timer. Okay. Thank Okay. So what I'm most worried about in this scenario is that falling off a horse is quite a high height to fall from, so it's quite high energy impact trauma. So she could have a pelvic fracture. She could also have multiple other injuries going on. So I would make sure this patient had a full A to assessment in accordance with a T. L s guidelines. Um, so, first of all, I'd like to make sure this lady is properly immobilize the C spine immobilization. Um, and we are in a and E, so if we haven't already, we put our trauma to call and get the trauma team, um, to come and help us assess the patient. So once we got the c spine immobilized. We can check for signs of external hemorrhage. Um, I'd then move on to doing a full primary survey. So I would assess the airway, um, for any obstruction, um, and then move on to breathing. We'd get oxygen, saturations and oxygen on her if needed. Um, I would assess the trachea. I would assess the chest for chest wall tenderness, chest expansion, percussion and auscultation in. Um, Then I would decide if I had any concerns. I would intervene and resuscitate as necessary and move on to see, make sure she's got two wide board cannily inserted. We'd send a full set of bloods. Fbc you any group and save clotting. Um, in case there are any injuries that might go to theater, we can get her BP and her heart rate. If she's sewing signs of shock, then we can resuscitate her either with a bolus of IV crystalloid or blood. Um, re SSC. And then we can move on to assessing her G c. S her neurology, her blood glucose. We haven't already sent a V B g. We can check it on that with the lap tape, um, and then going to fully exposed check for any other injuries and then proceed with a secondary survey. Um, and then we're going to make sure that, uh, well, if we could put a trauma call out, going to make sure that our seniors are aware of this patient in case we have any injuries. Um, and based on our primary serving findings were going to decide what's further investigations be required. Okay, so you've examined her, and she just has general tenderness, all overs of her pelvis. What are your top your pressure diagnosis at this point in time? So, um, knowing that she's she's got pain in that area. My my most concerning one would be that she's got an open book, pelvic fracture and an unstable pelvic fracture. So if she wasn't already, I'd make sure that she was in a pelvic binder. Um, if she does have a specter pelvic fracture, she's most likely going to need CT scan imaging of her pelvis. Um, best case scenario would be that if there was a fracture, it was a neck of femur fracture. Um, because it's less life threatening as less risk of vascular injury. Although still serious, um, it it could be pubic Ramus. There are lots of things that could be fractured, but I think this lady probably needs CT scan imaging. When the folk Bindoon place you have enough to take a focus history examination by a register on call. What are the things that you were asked for in the history And what sort of examination findings are you looking for? Um, so I'm gonna take history wise. I'm going to take an ample history. So I'm going to check allergies, Uh, past medical and surgery history medications. Last meal was, um and we confirm the events of exactly what happened. Um, in terms of examination, we're gonna do a full neuro vascular assessment, particularly of the lower limbs, to make sure that there's no suspected vascular injury or potentially any lower spinal cord injury. Um, that could demonstrate some neurology there. Okay, so you've mentioned a bit about investigations, so at this point, you've got about a minute. You've got five minutes, so you need to give a slicker. But let's just do the last question. Um, So what is your immediate management of this patient? Uh, so my immediate management would be resuscitating this patient based on the observations as we go along. Um, has already mentioned we've got the trauma team. We're going to make sure she's got a CT scan. Okay, so a CT confirms that she's got I don't know, extensive public fractures everywhere. What does your management of this page, they're gonna escalate to the encore. Orthopedic registrar. Consultant. Um, we're going to, uh, probably ask for a CT angio second phase of the pelvis check. There's no vascular injury if they haven't already done it. Um, and then we're going to make sure that, um, after discussion with the Reg, if we're planning theater going to make sure that all the investigations are done to e c G speak with theater coordinator and anaesthetics to assess the patient if they haven't already attended the trauma. Cool. Okay. Well, how did you think that went? I quite like trauma. Yeah, yeah, yeah. Faster in the A to we and not waffle quite so much, but otherwise relatively happy. Yeah, so I think that was very good. And I think you've covered all the main points. You obviously know your 80 really? Well, um, and you you sort of escalated the patient, which is excellent. and you ordered your appropriate investigations. So those are tick, tick, tick. Great. Um, if I wanted to pick it to be picky, I would probably say, uh, you do need to concise your eight to a little bit more. I think that covered about 2.5 3 minutes, which didn't leave a lot of time for questions. And you get bonus points for the questions. So you do want to give them time for that? Uh, the differential question, I'll probably say, Probably just I think what they're looking for is a list of differentials, so just goes off the most likely how how I would approach is the most likely will be perfect. Sure, but things are Would other possible diagnosis would be like, Oh, from a fracture hematoma, soft tissue injury. And that's it. I would just leave it for because there'll be questions coming after about investigations. So let's have a look. Uh, so differentials. Yet power structure. You've got that neck of femur. You've got that at dislocations. Ligament, muscular injuries. Hemotomas history wise, you mentioned Temple, which is excellent. I think for myself personally, I like to say medications such as anticoagulants because it shows that you're thinking about them going to theaters. Um, examination. So yep. You mentioned looking at it. You mentioned palpating deep pelvis and pelvis, which is great. As I mentioned earlier. People always forget this but digital rectal examination because you do want to check whether there's any, uh, neuro involvement and also, um, pelvis fractures. As you might know, they're often associated with us trail and bladder injuries. So you do want to make sure that they're passing urine. They don't have a high riding prostate stuff like that. And then you mentioned your Bhaskar deficit, which is good. Based on investigations, you've got E C G BBg perfect. Um, I'll probably add on bladder scan as well, because, as I mentioned earlier, sometimes you can have your extra injuries and there might be retention. And then you've mentioned about CT, which is excellent, uh, management wise, you escalate it, and that's great. But I remember someone wants it to meet. Anyone can escalate, but what would you do? So you yourself after you're escalating, you're not just standing there, so I don't think you've mentioned about giving the patient and algesia VT you. I don't think you mentioned about giving them new by mouth and IVIS so need to solve get sort of the basics as well. Just what you can offer the patient rather than just ringing the registrar. But you've got public blinded binder, which is excellent. And then you've got escalation. And then once again, just discussing the patient relatives and documentation. So that was great. Well done. Any questions? Uh, anyone, actually, anyone has any questions about the trauma station at all? James, you happy we've held? It went any questions about the Thank you. Good. Thank you. And then I'll just That's the end. And then I'll just pass on to Adam. Thank you very much, Chloe. Thank you, James, for volunteer. And, um, next up, we've got Adam McLean, who is a post, um, post course surgical training fellow who is particularly interested in e n t. Hello. Right. I don't have a camera on this computer, so you'll just have to settle for my voice. Unfortunately, um uh, Vinny AC, I'll answer your question at the end because I do actually have some reading that's relatively useful for clinical stations. Um, I'm going to give you a slightly different look on this than Chloe has just because of how my interview went. But former, as Chloe said, two stations management of clinical, 10 minutes each. No break. He used to have a five minute window where you could look at the first clinical station, but they've got rid of that. Over the last couple of years, you're being scored on your clinical skills and knowledge, your judgment under pressure and your communication. You get a score of 1 to 6 on each, and they're equally weighted. Um, each question is gonna be on a single patient. You'll be asked to assess, investigate and manage them. The problems are pretty variable, but you tend to have an 80 lesson of crisp. They do throw curve balls in. I got asked about a completely well man with a slightly red knee that you've had for a while. Um, and I know they used that again last year, So be ready for an A two e where everything's pretty much normal, and you need to go a bit more into investigation and management and long term care. But 95% of you are going to get to acute cases. Um you might be asked follow up questions or you might speak for the full five minutes. Neither means you've done well or badly if you're getting a very difficult question at the end, you probably done well. I was not asked a single follow up question. I spoke for five minutes on Question one, and then I spoke for five minutes on question to my examiners. Didn't say a word. That's my feedback from my interview. So those are my credentials and why you should listen to me if you want to know about what sort of scores you need, Um, I ranked about 1/100 with that. So yeah, it's That's a reasonable score. But some people just absolutely smashed the portfolio station. I had to catch up a bit. So crisp algorithm. I'm hoping most of you have done the crisp course. It's very, very good Course. If you haven't, it's even worth doing in CT. It's not just good for getting into court surgical training. It actually is beneficial. You're thinking about your immediate management, which is you're a two e. Your full patient assessments are looking through their charts, their notes doing a history systems exam what available results you've already got. What available results? What results you want that aren't yet available? Then you're deciding and planning. Are they unstable, or are they stable? If they're unstable, what do you need to diagnose? What you need to intervene with straight away, to keep them alive and to treat them if they're stable? You're thinking about your long term care, your daily reviews and all the things you need to do with that. Hopefully, you shouldn't be asked about your stable patient's, but it's always worth thinking about it, just in case. And then your definitive treatment generally can be split into medical, surgical or radiological. Can we deal with them just with medications? Do we need the radiologist to drain something, Um, or do we need to take them to theater now? Okay, thinking on the run. This is copied straight from the Chris book. Think early when the phone call comes, so use the nurse that refers the patient to you. She'll give you a little bit of information, but there's more you can obtain. You want to ask about the patient's observations in detail. You want to ask about what the patient's have done how long they've been in hospital? Um, why they're concerned, whether he's got worse recently or whether they've been this bad the whole time they've been in. And then you want to think about what you're going to do as you arrive. Basics. When you arrive your a B CS. What system has failed? What information is already available? What information can you get quickly, then what do you need to do in that first window? That 1st 10 minutes. That first hour to treat the patient. Okay, so my format was pretty similar to Chloe's. I open with. My initial concerns are so you'll get a bit of information about a patient. Give them your primary differential. What you're worried about, whether that be my initial concerns are this patient has got bowel obstruction or the patient has epiglottitis really give them exactly what you're worried about. If there's a couple of things that are equally likely, you can say them both. But that will tell the Examiner that you know what you're talking about. You're not just reading from your A to e script. I would ask the nurse to, so it's a telephone call if your question is a telephone call. Mention what you'd ask them to do while you're on the way. Things you can ask them about is, like I said, detailed observations. Get a fluid bolus ready until you prescribed it. They can't give it to get it ready. Pop some oxygen on the patient If she said they're saturation 85. Um, on arrival this I would say this verbatim or get your own sentence that you're happy to say that you've memorized saying it 1000 times on arrival, I will perform an eight We assessment of the patient following. See Chris principles. If the patient is conscious and alert, I would take a simultaneous history. That would be your opening statements. Okay, Next, you want to expand on your A B c D. So, like I said, I just spoke, so I didn't have any questions. So I as I was going through my a to a I mentioned each management step that I would do for each abnormal finding. Um, once you've finished your a to get into the specifics of history. So what things are you actually after? That's your ample Um what investigations are you going to do. A few of these will be included. As you go through your a TUI. What management are you going to do after your initial resuscitation? Where are you going to escalate them to? When do you want to reassessment assess them? Do they need theater? You're going into surgical training. A lot of these patients are going to need operating on. That's going to be a bit of a mentality shift from doing medical jobs as a foundation doctor. Okay, if there's any questions as I go, I tend to talk a bit quickly. So just pop them in the chat and I'll pause. Okay, so you're right to the assessment. It is very easy to learn. You should already be experts at it. Work on making it slick. Five minutes goes past really, really quickly. Um, you want to focus it on your likely abnormalities in the case. If the patient's got Abdo pain, they've probably not got an airway problem unless it's already been mentioned. So you can do your airway in 20 seconds, but you want to focus a little bit more on your exposure, Um, and describe your possible interventions as you go or keep revisiting that as I go through with some examples. So anyway, this is how I would phrase it. You assess the patient's airway, ensure they're speaking to you comfortably with no added sounds. If they're not which you probably getting the information in the question, inspect the airway directly. If you have any concerns regarding a compromised airway, instant escalation talk about who you'd need airway maneuvers and adults. The only real airway case you're going to get in the secrecy side of things is something like epiglottitis around a phylaxis. So think about adrenaline, either IV or nebulized steroids and ultimately, a surgical airway information to have in the back of your head. But it's pretty unlikely to come up in the crisp side. If anything, you're more likely to have a traumatic airway breathing assessment and treatment. And this is how you should be thinking about these. It's assessment and treatment, not just assessment. So make your ideas specific to the case that the pain of the patient that you're dealing with assess the patient for signs of respiratory distress, including the respiratory rate and accessory muscle use. Obtain an oxygen saturation, give oxygen if required. Initially. 15 liters via non re breathe. Even if they've got COPD, that's still the the rule. If they're hypoxic and you're worried about and just stick them on 15 liters Oscal. Take the chest for evidence of pneumonia, hemothorax, infection overload or Post Operative eight. Alexis. You can change sentences like that, depending on the case you've got. If you've got a patient who's pyrexia with a cough that you're going to say, I'm looking for evidence of infection. If you've got a trauma patient who's saturating 60 looks like they're working really hard and as a trickier all the way to the left, you're saying you're going to say you're looking for evidence of new, more human pneumothorax? Um, pop out the chest and take a look at a symmetry. Surgical emphysema. If they've had saying a suffrage ectomy, it's worth considering, um, or if they're a trauma case, that where something's gone into the lung, Ask for a chest X ray or an A B G if it's relevant to your management. But don't expect immediate results. And don't say you pause. You're a two way to do a chest X ray and give additional treatment based on likely causative factors. So in the very unlikely case that they're wheezing, you've given some self beautiful. That's probably not going to come up in a surgical question. Circulation assessment and treatment. This will probably be the bulk of your C crisp question. Uh, so again, the top and bottom line of each slide is the same. Make your idea specific to the case and give additional treatment based on the likely causative factors of the problems you find. Assess the peripheral and central perfusion assess for hemorrhage and volume loss. You can mention this in see or you can mention this in E or even you can mention it before airway. If you don't thinking of massive hemorrhage as long as you mention it. Once with a POSTOP patient, think about drains, catheters, any tube that leaves the body that might be taking blood or volume away from them. And make sure that you check those or ask the nurses how much has come out of them recently. If they've just emptied a liter of blood from the drain, you're not going to know that they're draining anything because the drain will look empty to you. Palpate pulls, check BP Oscar. Take heart standard stuff and then fluid bolus. So see crisp talks about 10 to 20 mg per kilo. Or you can say 500 mills and reassess. Just mention a bolus of crystalloid. As long as your phrasing is safe, it doesn't matter how you say it hemorrhage like we talked about. And, like Chloe mentioned, reversing blood thinners might be worth thinking about an immediate intervention versus resuscitation and reassessment with more relevant to your trauma patient's. Then you want to say that you'd put two large bore cannulas in. Take bloods from them, asked for an E C G after your 80 and a catheter and always justify your decision. So if you're going to take blood from the patient, if you think you've got time, I would say I do a full blood count and the CRP to assess for an inflammatory response and evidence of infection. I would also want to check the hemoglobin to see if they're bleeding. If the patient's say had a lap coli and has got pain, you would say I do some liver function tests to assess for abnormalities in case of, say, a bio leak. You want to do a clotting and a group and save in case a patient needs to go to theater. If there's evidence of bleeding and cross match that and make sure that I request some blood as well. If they're pyrexia, I would take blood cultures as I'm worried about sepsis. If you pop a little thing after each investigation justifying where you're doing it, they're going to think you know what you're talking about and that you're not just reading from the script that you practiced 1000 times, um, and again based everything on the case that you've been told about dysfunction of the CNS and treatment should be very, very quick unless it's, uh, specific to, uh, the problem. So initially, you say you've taken a pu. If you're worried about their cognitive state, say you do A G. C s later on in your secondary survey, you check the patient's blood glucose. If their postoperative think about, Are they diabetic? If they not been eating, what insulin have they been given? If you mentioned these things and then think about Peca's opioid analgesia postop as well, if they're drowsy, so say that you'd want to know if they've had. You'd want to check the drug card further down the line, Um, and then exposure wise. It's a little less relevant than it is in a TLS, but you'd want to do a detailed examination of the relevant area. So if the cases that the patient's got abdominal pain so you perform a full abdominal examination because auscultate, um, you probably want to do a P R if you have any concerns of bowel obstruction, if it's, you know, a patient with stride or you do any full examination of the neck, make sure your your primary thing in exposure is the problem that the patient has. But then talk about doing a full exam of the patient further down the line. Check the calves for DVT. A lot of these patient's will be post up, and then again, if you've not mentioned it in circulation, you want to talk about your drains, lines, tubes, catheters, anything going into or out of the patient. So you've done your full A to A and you probably used up half of your time. I would then move on to a very brief history, depending on the outcome of your a to eat. If you've been given a patient that's clearly critically unwell, you take very little history. You'd be rushing them through to theater. If you've been given a patient that's a little bit more well, and you think you've got the time to take the history, you have a bit more time to talk about this. So for history, think about just as you were taught in medical school. But then think about what's very specific to the case. Was Chloe talked about with ample chart Review is important, and this, I think, is where you score those final few points. So you'd want to look through the patient's notes, in particular the operation note. And I can't stress enough how much they enjoy you saying the words operation? No, it was the only time my interview has smiled in the whole 10 minutes I was in there. Um, the reason you're looking at that up no is to see if there was anything abnormal in the operation that might help you come to a diagnosis. You don't need to be more specific than that, as it might not be an operation, you understand. But just in case there's something that was particularly difficult. So they had an adhesion that was particularly difficult to get rid of from the abdominal wall might indicate that there's a bowel injury, that kind of thing. Um, also look at the most recent war drought plan. Also say that you'd review their drug and fluid chart for contributing factors to their condition. Now that might be that they've had a lot of anti hypertensives or that they've not been getting IV fluids. But you don't need to go into that much detail, say that you'd review them. Um, and you'd look to see if the patient if you're concerned about sepsis, I would say I'd look to see if they're already on antibiotics and consider escalating these, if necessary, review the patient's observations for trends. They might be improving. They might be worsening there, almost definitely worsening because it's an interview and then review their fluid balance and their drain outputs as well that you should all be able to say in 20 seconds. Investigations wise, you should have covered most of these in your a two way. You have asked about a chest X ray and a B G. Your blood tests But it's about what other investigations you need to come to a diagnosis. So what plain films might you want? Do you want to see t and why? Um, if they are going to ask you a question, it will be. Why do you want a CT? They don't like trainees just asking for a scan that solves all their problems. So be ready to justify the CT. If they ask that, give them your differentials and explain that a CT would be able to demonstrate these. If you're asking for a scan for something, that scan won't show, you're gonna lose some points. Uh, whether or not you want an e c g in an echo, E c g, you're gonna want it. An echo is pretty unlikely. Um, and then blood cultures, urine cultures, chest drains, lines, anything you can culture. If the patient's septic management and escalation again, most of your management you should have gone through as you were talking through your ate away. Most of the things that you can do as a CT one will have already happened. So a lot of this is about what you want to have the patient to have done next, and who you need to speak to to get that done. So if you think this is a good point to pause, get your thoughts together and think about anything you may have missed because you've got a little bit of time to say it. So I think this is the first time I breathe while I was talking for my patient, Um, who do you need to speak to and why? And where does the patient need to go to? So patient's got an orthopedic problem. I would speak to the orthopedic. Reg is I believe the patient need urgent operative intervention. I would also speak to anesthetics, as the patient may need. I see you post up and they will need to come and do an anesthetic assessment of the patient prior to him going to theater something like that. Say that you would use an s bar format just so that they know that you're going to do a nice quick handover and think about how quickly they need intervention. If you don't know if you've got no idea what this patient needs say that you would discuss with the relevant registrar about whether or not. They require urgent operative or radiological intervention. And if there's anything else the registrar would like you to do in the meantime, to finish things up. If you've got any time left at this point, which you probably won't say that you would explain the situation to the patient, document your assessment and advise the nurse on your escalation plan so you would tell the nurse when she should contact you or when you're going to assess the patient again. So the simplest way to do that is to say, Please let me know if the patient clinically deteriorates if you have any concerns or, for example, if the urine output falls below 30 mils per kilo per hour, some key factors that make you worried. Okay, any questions so far? I'm conscious. I talked very quickly there. It took me a lot longer in my practice. I don't Do you mind if I say something really quickly? Um, so I think, um, Adam has approached it fairly different for me in the sense that he's off, said he's talked all five minutes. I think that's a really good approach to it, too, whereas I've sort of passed and weight. I think the difference is depends on whether you know what's going on or not. If the diagnosis is very obvious, for example, and you're very confident it might be worth you just sort of saying everything in five minutes because then you take off of the points without examiners asking you. But I think that runs the risk of if you don't know what's going on. For example, if a patient is not septic and they're bleeding POSTOP and you go down the sepsis route and or you talk about sepsis. But turns out the case is POSTOP bleeding, then you might be just spending five minutes just going down the wrong route. So I don't know, quite interesting. Yeah, I think it's reasonable, I think, if you are not sure taking a pause to see if they'll ask, your question is fine. Just be aware that sometimes they might just stare at you. And if they do, just stare at you, carry on. So I know of people who did pause and weren't asked anything. I know I didn't pause. I know of people who were asked questions. It's supposed to be a structure, but It depends on who you get. It is very, isn't it? Just read the room and see how it goes. I guess they're looking for safe clinicians. All methods, as long as what you say is sensible, are are okay. Um, I think I just gave them such word soup that I covered what they were going to ask me anyway. So I have an example Case as well. I'm going to go through it stage by stage rather than have you one person drilled for five minutes. If someone wants to go through a stage by stage on microphone, that's great. If not, then I'll ask you all to put some stuff in the chat about what you put for each part of my, uh, set up. There's any volunteers who want to go through it in the, um on Mike and let me know. Uh, fair enough. So here's your example. Case her nurse calls you to review a patient. She's worried about these two days post laparoscopic cholecystectomy and looks on Well, she's done a set of obs. He's pyrexia and using a seven, and he's complaining of abdominal pain. Initial concerns pop in the chat. What's your immediate differential that you think needs to be assessed for here. Very good by a league mentioned twice. Hemorrhage. Good POSTOP, bleeding good. CBD injury. Yeah. Collection. Yeah. So abdominal pain, high news pyrexia. We'll post up first thing that jumps to mind is infection And the thing about likely causes of infection, probably something to do with the bile ducts in the lap coli hemorrhage is also reasonable. We don't know if that high news is due to loss of circulating volume or what it's about yet because we've not been given specific. So I think those are the main things should worry about other things I've mentioned. So my main concern is sepsis. Secondary to a Bilek. Other possible but less likely cause is our chest infection. So you can get a hap with POSTOP atelectasis wound. Infection can still cause abdominal pain. If the patient just says my belly hurts and no one's taken the dressing off bowel and abdominal organ injury, something else may have been damaged. Most likely thing to be damaged in the lap cold is the CBD. So I agree with you too good. Anything you guys would ask the nurse to do initially, you need to use everybody available to you when you're on call. It makes things a lot easier. Oh, I wish the nurses with catheterized Patient's excellent. So full set of observations. Yes. So the key thing I wanted from that was get the observations in numerical form. So I would ask the nurse to tell me all of the observations. Apply oxygen. If the patient's hypoxic, prepare a fluid bolus and let me know what the patient's urine output was. I think it's reasonable to ask them to catheterize, but they're not going to. So I might not include that when you've only got five minutes e c g as well. Yeah, good. But they probably won't get that before you get there. So that would be all. I would include again 5, 10 seconds of your speech. What are you going to do on arrival? I'm not going to patronize you. You do that really important that you get a sentence that you're going to use for any patient down that you can just rip off in a couple of seconds. So this was similar to what mine was. It was a few years back to. I can't remember the exact of it. Chloe's is better than mine. It's got a bit more detail to it, But think about your sentence that you're going to use on arrival or performing a B c D assessment of the patient following Chris principles. If the patient is conscious and alert, I'll take a focus history simultaneously and you're into you. A TUI Airway. Anything specific in our way. Okay, I hope so. Ensure that there comfortably talking to you with no added airway sounds it. It's not the case. I'll perform a full airway assessment, and I would leave it at that. This with the crisp station if they have not mentioned something. Airway in the question. I think you can work. Be very quick in your airway assessment as long as you've clarified that you're going to check it first. But that would be about as much as I would say about that breathing. You can have a little bit more in. So again, I think I can skip through this one because it's going to be generalized stuff. But this is how I would say examine for increased work of breathing. Apply a pulse oximeter and give supplementary oxygen via 15 liters memory. Breathe if hypoxic because and auscultate the patient's chest in particular. Listing for evidence. Pneumonia. Given the patient's pyrexia all consider taking an A B G. Based on my findings, that will give me better information on the patient's oxygenation, as well as a pH lactate and hemoglobin, which we use for my overall assessment. The patient. If I have concerns about the chest, I would request a portable chest X ray following my 80 assessment 20 seconds. We think this is an abdominal problem, that a chess problem will kill them faster and sometimes upper abdominal pain can be nasty chest infection plus collections postop things like like Kohli's can end up giving you a chest infection, so that should cover all your bases with breathing. You see how I'm justifying each thing I've asked for and also getting my investigations and a bit of my management into my ate away so I don't have to go back and say it again later. There's quite a bit in circulation, so just pop a couple things in the chart that you'd be considering doing for this patient specifically. Yeah, excellent. Good God, you can barely read that. Assess the patient's overall appearance of circuitry shock, peripheral central pulse rate, rhythm and character check, BP and capillary full time for evidence of high for bulimia. Likely secondary to sepsis. Again, I'm justifying it within the case rather than just reading from the script. Check the patient's drains, if presently might have a drain post lap coli. So this is worth mentioning for evidence of hemorrhage. Uh, if they demonstrate evidence of hypokalemia or sepsis, I would give a bolus 500 mills is fine to say 10 to 20 mils Fluke crystalloids. Fine to say. You can mention if they've got a history of heart failure, you can start giving a smaller bolus, depending on how much you've already spoken for. How your time's going, um, check for peripheral access, insert wide, but cannulas obtained blood tests and then you can see on there. I've justified each of my blood tests. Um, again, you've got to keep an eye on the time, but it's worth saying this because then they won't ask you about why you're doing certain blood test. You've already covered it, Um, and if it's in your head at the start, Things tend to flow a little bit better. So key things in a high news. Likely septic patient. Inflammatory markers. Hemoglobin because the POSTOP clotting in a group and safe because they might go back to theater. Or they might need a radiological drain using these because you're looking for an AKI, an electrolyte imbalance. If you've not been eating for a couple days POSTOP, they might be hypokalemic LFTs. They've had a lot coli. The LFTs are deranged, and they might have a bile leak or an injury to the bile duct and then cultures because they're pyrexia. Well, ask for an E C. G. As I think, one of you said, because they're tachycardic and sometimes abdominal pain can be referred down from the heart. That's pretty unlikely here, but don't interrupt your assessment to perform this unless you're concerned they're having a stemi. It's not part of an initial lately because it takes longer than an entire ate away. I'll flick through these two because there isn't a huge amount here, but I have Peace Corps. Consider a G. C s and neurological examination. If that's abnormal political glucose, you've already done an a B g. So that will give you a glucose. And then they might have a P cash machine on. So assess for over use of opiates, given they've had a recent operation and then have a look at the pupils exposure wise. Somebody's already said abdominal exam. What sort of things are you looking for? An exposure? Yeah. Brilliant. Um, Another thing that surgeons love. Look at the wound. Mhm. Give you another 30 seconds. Fair enough abdomen. So observed. Help a Oscar. Take the patient's ultimate turned on this. Distention checking for bowel sounds. They've had an operation. They could be an alias. Bowel could have been damaged. Could be obstructed or perforated. Check the patient's wound sites for evidence of discharge or infection. Check the drain. If you've already said you're gonna check the drain, you don't need to repeat yourself because you're just using up precious time. Check if they're catherized and the urine output over time again. If you've already mentioned the catheter, I wouldn't repeat yourself and then you would insert a catheter. If they don't have one, I wouldn't say Consider inserting. I would just say you put one in, um, full exposures of patient to access for any other causative factors for their high news in particular. Check for evidence of DVT. I would throw that line in to just about any patient in the crisp side of things or a similar line to that just because it covers all bases. Check the patient's temperature. Given the evidence of concern for sepsis, I would commence broad spectrum intravenous antibiotics. You can say this in a few different points. Some people might start in circulation. Some people might start in exposure. Some people might say it in their management plan after they finish the rate away as long as you mentioned it once, it's fine. You're not going to be penalized for putting antibiotics in a strange points in your talk and then think about doing a PR exam. General surgeons love a PR exam, but only really, if you've got concerns regarding by all obstruction. So any particular points from the history we're gonna want from this guy. Oh no, brilliant. Someone's listening. Did they perforate the gallbladder while they were operating? Was their anatomy confusing? They have to put a couple of extra clips on all that sort of thing all you need to say is I would review the up note mhm any other common sense stuff from a history of a patient. You're about to give antibiotics, too. Fair enough. We're an hour in. I'm just going to drill through Focus history of the patient during my examination. Symptoms. Evolution over time. Relevant past medical history. Current medication, allergies, Allergies is the important one there. Um, ample is pretty good. Keep that in mind ops. Trend. Very good notes review So we'll go straight into that. We're talking about up Note already. Review the patient notes. In particular, the operation note just may give me information regarding the likely cause of the patient's symptoms if the operation was difficult and that that's another sentence you can use, regardless of what operation they've had. Just tells the Examiner that you're thinking about postoperative. Uh, Iatrogenic causes the patient's symptoms. Review the medication of fluid charts to assess what management the patient has had since his operation. A particular concern would be anticoagulants. I put antihypertensives in there as well as the anti If there, um hypovolemic um, check out the patient's already on antibiotics and escalate these investigations so don't repeat yourself. We've already asked for the majority of important investigations. You can mention your septic screen here for this patient particularly, and you a chest X ray. If you've not already mentioned it, think about plain films and then think about more detailed imaging in a lot of patient's. Plain films are going to have a huge benefit outside of a chest X ray. In any orthopedic patient, a plain film of the bone that you think is broken is going to be useful. And a general surgical patient if you're going to ask for an abdominal x ray, justify where you're going to ask for it. So only, really, if you're concerned about obstruction, are you going to ask for an abdominal X ray perforation? Specifically chest X ray free air under the diaphragm? And it's worth mentioning that in any patient whose tender in their abdomen after an operation, I would then say I would request a CT scan of the abdomen and pelvis to assess for a biologic abdominal collection of bleed. But I would discuss this with my senior first. What you could also say that would speak to my senior about whether this patient warrants a CT scan if you're not sure. So the important thing when you're getting to the more complex stuff is if it's not a specialty, you know, a huge amount about, but you think something would be warranted, you can preface it with. I would discuss with my senior whether this would be necessary because ex wife said, If you really don't know much about the specialty, then it's probably a good time to pause and let them ask you some questions. I would also ask for hourly input output monitoring. You want to know what's coming out of the catheter. You won't know what's coming out of the drains, and you want to make sure they're getting plenty of fluid in that they're responding to fluid and management wise. So I will ask for some answers here other than what we have already done. We've already put this patient on oxygen. We've already given them a bolus. We've already given them antibiotics. What are we going to do to finish up here? What are the management things might they need? Okay. Yeah. Excellent. Make the patient nil by mouth. Yeah, well, now you're thinking like a general surgeon Analogies your antiemetics good. I'm definitely, uh, corporate of forgetting to give painkillers. Fine. So none of you are whisking this man straight to theater. So this is where you talk about reassessment. So you've done a bunch of things for this patient, and the biggest factor that's going to affect what you do next is how they've responded. So I would then reassess the patient following resuscitation. I would give a further fluid bolus if required. The patient further deteriorates does not improve. However you want to phrase it, I would request urgent assistance and then explain what assistance that would be. So escalate this to the surgical registrar, Discuss performing a CT scan for Bilek. Escalate this to outreach, or I see you. But whether the patient should be prepared directly for theater or should be transferred to a higher level of care, um, then talk about they may ask you this towards the end. See, they may tell you what the scan shows, Um, but if you like me and you just talk continuously, if the scan demonstrates a collection, I would discuss whether operative or radiological drainage would be possible for source control. So we talk about classifying a lot in surgery. A very simple classification, as I mentioned at the start, is. Does this patient need medical, radiological or surgical management of their problem? Now? You don't necessarily need to know the answer to that, but you should mention that those are the things you're considering and finishing off. You're done. You're fully assessed and treated. The patient. Your registrar is on the way. What are your closing statements going to be? Document. Speak to patient and that's brilliant. Escalation pound. Brilliant. Know it's an inform. Yeah, these are the things that take 95% because you've done everything right up to 100% because you remember to do the little things that you do if you're actually on the job. So explain what's happened and the management plan to the patient. Document your assessment and plan. Informed the nurse to contact me if and then base that on the clinical station. But if you don't know, just say patient clinically deteriorates or if she's concerned, nursing concern is always a good thing to mention ensure the patient has whatever treatment he's going to need. Down the line maintenance fluids prescribed admitted his antihypertensive to the morning, that kind of thing, and that's it. Now, the first time you do that with one of your colleagues or in front of a mirror or whatever, it's going to take you 20 minutes, and each time you do it afterwards, it'll get a bit slicker in a bit quicker. Um, practice practice practice is the biggest thing. You're all smart enough, and you will probably have the surgical knowledge for the majority of these cases that, given enough time and enough prep, it would be really easy for you to do all of the things we just said. Um, the issue is getting it into the time frame and sounding like you've got a structure instead of either panicking and saying everything that comes into your head when you say it or go only getting through half of it by the time you're time runs out, make sure your assessment is adapted to your differential so they know you're not just reading from an A to e script and make it clear what you're thinking about. They don't know your train of thought. You need to express that, justify your actions. I've put any idiot can request a CT there. That's from personal experience. Um, oh, no, I will mention for the fifth and final time. If you don't say it, you'll lose a lot of points. And it's such an easy way to score a few bonus points. And then often it will come down, too. Can they go to CT, or do they need to go straight to theater and in a TLS questions? They often ask this, and I know people have been interrupted while talking about CT scans, so be ready to answer. Is this patient suitable to go to the scan? Er, very simply, yes or no? If yes, with a medical escort. If know you're saying that they need to go straight to theater, that is, if they're not suitable for the scan, er, then pretty much your only option is emergency operating. So it's worth thinking about that before you say CT scan, because they will ask this link at the bottom. It's what I used quite a bit when I applied. It's probably a little bit out of date now. They say they have done a 2021 version, Um, but it's about 100 and 50 page guide with a bunch of different examples of clinical stations, and it will give you a good general overview of the sorts of question they ask. Um, it's quite a useful thing to do for your last few weeks before interview, um, your knowledge you should already have or from hopefully doing MRCs and things. But it will help remind you of each of the different specialties and the sorts of things to consider. So that, um, I would recommend about people have not done a TLS because when I did it, at least there was a good few trauma stations in it. Um, there are lots of good online tools as well. Have a read through your crisp book. If you've got one. That's very useful. Um, but hopefully by now you'll have the knowledge. Really. It's about getting slick and quick at the way you speak. Any questions? Thank you so much, Adam. That was brilliant and really, really helpful and thorough. Um, if I thank you everyone for listening, I mean, if I could ask everyone to do the feedback form Once you've done it, you'll be automatically send a certificate for attending and it just helps us really hone in on what you guys want, Um, future sessions to be on and also enables us to give feedback to Adam and Chloe for their portfolio and to thank them for giving up there Thursday evenings to help us. Um, if I know has got any any final comments, you just want to pop them in the chat. Well, hang around for about another five minutes, and then we'll let you get on with the rest of your evenings. All right. Thanks, guys. Good. Look at your interviews.