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As part of this session, we will be teaching you key skills for reviewing acutely unwell patients, including using the ABCDE approach to manage common acute medical presentations during on-call shifts!


Join us for this session to learn key skills for reviewing acutely unwell patients, including using the ABCDE approach to manage common acute medical presentations during on-call shifts!

Learning objectives

1. To understand the structure of the on-call shift and the role of the on-call F1. 2. To develop a structured approach to reviewing deteriorating patients using the ABCDE framework. 3. To practise applying the ABCDE framework to common clinical scenarios, and to consider the appropriate assessment, investigations and management of these conditions.

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Computer generated transcript

The following transcript was generated automatically from the content and has not been checked or corrected manually.

I'll just go over it briefly. Um So shifts are generally split into day team which is usually eight till five. Sometimes it's nine till five. Then the day team will hand over to an on call team in the evening which will cover the hospital between five and usually nine and then a night team will take over. Um And between each of those, uh the unwell patients are handed over, generally, the on call team only deals with urgent things that can't wait until the next day. So um routine things, they're best left to the day team that are the patient's usual care team because then the um of care is much better. So just urgent things on call. Um So the tasks for the on call team are um in summary, they are reviewing and managing acutely unwell patients. Um Inserting Cannulas and catheters that um the nursing team aren't able to do um requesting and reviewing urgent investigations, changing urgent medications, clerking new patients and then um responding to any uh escalations from the nursing team about newly unwell patients. Um such those with high new scores. Um and then if needed escalating that to a senior um and or updating the relatives of that patient, all the other things like stable patients, discharges, non urgent medication changes, investigations that should all be left to the day team. Um Nick slide, please. Thanks Gary. Um So I'm sure you all know by now that um the way the general approach we use is the ABCD E approach um for patients. So at the start of an on call shift, you'll receive a handover. This might either be in a big team meeting at the beginning of the shift or it might be over the phone, um, from another doctor or from a nurse. Um, the next thing that's, uh, good to do is to just have a quick look at the observations in our hospital observation are online. So, um, it's quite easy when you're on the phone, when, when a nurse calls you, you can start looking at the observations as they're talking to you and gain a picture of the patient. If you're worried, go straight and review the patient and do your a. Um, but if there, if it looks like there's a bit more time, um, it can be quite helpful to review the medical notes, see what's been done so far. What are their comorbidities, what medications are they on? Um, because that can then help you with your assessment. Um, then you'll need to commit to an impression at the end of your notes, make a plan. Um, I would suggest just ma just try making a plan. It feels scary but make the plan, write it down and then discuss it with your senior. Um Go through uh an SBAR approach is a really helpful way to hand over. So situation um background, what your assessment is and what you think we should do and then ask for their advice and for their recommendation. Um And then as always, make sure you document. Um So by now, I'm sure you all know um A to e it's the easiest way to answer any ay or any um any question from a senior. How do, how to approach patients say I would do at e um I'm not gonna go through this in detail cos I'm sure you know it, but it starts at airway. So you want to check, are they talking to you? Um, or perhaps they're very drowsy. Um Are they snoring? Perhaps they're obstructing their airway? Um Maybe they've got vomit in their mouth. Um, airway is the most important thing. So um we can use airway a adjuncts if they are, have a low G CS and aren't maintaining their own airway anymore. Airway adjuncts in the um you know, like a nasal pharyngeal airway or a oropharyngeal airway or a Cadel um to tie them over and you want to be getting on the phone to ICU or anesthetics quite quickly if you think they might need a definitive airway. So, um an et tube. Um suctioning is also very good for clearing airways but only have a suction where you can see um B that's respiratory. So um breathing respiratory rate. SATS have a listen to their chest review. Any imaging chest X ray. Have they had an ABG? Do you want to do an ABG uh what's their COVID status? C? You want to be looking at their heart rate and their BP on their obs, you want to be feeding their pulse? Is it a good volume or is it very thready? You want to be checking their capillary refill time? Are they cold and clammy? What's their urine output? Um, if a patient is cardiovascularly depletes or, you know, not perfusing their organs very well, kidneys are one of the early things to get hit and urine output will reduce and they will go into an AK a pre renal AKI. So urine output is a very good indicator. Um, have they had a nice ECG or perhaps do you need to ask the nurses to do an ECG? Um, have they got a Cannula if you need to put one in, do you need to send bloods at the same time and have a look at what bloods they've had. Um, d er, don't ever forget glucose. Uh So check the BMS. Um that's on a VG. Uh if you've done one of those, um, check their pupils, check their temperature and do a G CS. Um, if you're struggling with G CS in the moment, AVPU scale is more than acceptable. Um, G CS really was formed to assess patients with head injuries. But um, yeah, we, we, we use it more generally now, but if you can't remember it and you're panicking AVP is fine. Um, and then lastly, you want to do a bit of a kind of everything else. Have a look at their abdomen. Are they periton? Have they got pain? Have a look at their calves. Does it look like they got a DVT or are they fluid overloaded up to their knees? Um Look for any rashes or signs of bleeding. So that's a general at E approach. It's quite structured and it could be a really lovely thing to fall back on when you're um given an unwell patient and you're panicking a bit, just go back to at E. Um So we're gonna go into some scenarios now and show you how we can put some of these into practice. Um So I'm gonna start with the first scenario. So three altogether. Um So imagine you're on and on call. It's a busy on call. You've got a huge list of things to do and you get a bleep from a, a nurse on ward nine saying doctor Mr Chan in bed seven has become really short of breath, please. Can you come to review? Um So I'm hoping to make this as interactive as possible. So if people could put in the chat. What sort of things would you want to be asking this nurse while you've got her on the phone? There's no wrong answers. So, just type in anything you can think of. Yes. Can anyone think of anything? So, you've not got very much information there? Yeah, that's fantastic. So, the first thing you want to know is kind of, what's their use, what's their observation, um, observations doing? how short of breath are they? Um past medical history is really, really helpful. Um Knowing kind of why they've come into hospital. That's, yeah, definitely super helpful to know. Um any other things you can think of practically what can be useful. And the thing that I'm thinking of is what's their hospital number, what's their, some identifer identifies things like date of birth, full name? Um What ward are they on? Um, what bed they're in things like that. So, you know, where to go. Um So we've got a list on the next slide. So these are some of the things that I thought it might be helpful to ask um while you're on the phone. Um So asking what their obs are. One useful thing that can be really helpful is to ask if they're worried. So knowing whether a an experienced nurse on, on the ward who's, who's likely been working for a lot longer than we have as f ones is worried about a patient can be a really good indicator about how well you need to be getting yourself there. Um Asking if they're on oxygen is helpful based off what their users, um what they've come into hospital for like you've said and whether they've got any other medical conditions. So you ask the nurse these things and he gives you these answers. So um Mr Chen is meeting of 10, so he's not doing very well. His respiratory rate is really high at 30. His stats are 81 on air. His blood pressure's a bit low. He's a bit tachycardic. He's confused and he's spiking a temperature. The nurse is very worried. So wants you to come straight away. Um, she's put them on 15 L non rebreath mask in the meantime, um, and they were came into hospital because they were short of breath coughing and were a bit confused for the last three days. Um, in terms of other medical conditions. So the patient's got co PD hypertension and type two diabetes. Can anyone think of any other follow up questions you might want to ask? Based off those answers the nurse has given you on the phone. There's a couple of things you might want to clarify if you're able to on the phone. Yeah, that's super helpful. So, is he on any medications? So particularly one thing you might want to know is if he's on any antibiotics, if he's come in with those symptoms, is there anything else you might want to know. Yeah, that's super helpful. And why would you want to know that whether he's got a recent ABG or not? Yeah, you don't s know as recent bloods for sure. These things in reality sometimes are easier to, to get um, yourself when you're, you've got an online system and things getting someone's hospital number and being able to look everything up remotely is super helpful. But um the nurses sometimes can answer these things from their handover sheet and are often super helpful with stuff like that. Um But yeah, knowing if there's respiratory failure is really helpful, some of the things that I'd written down that jumped to my mind based off that was what is sats are doing now. So she's put him on a rebreath, not 50 L of oxygen. And if sats were 81 on air, what what's happening now that he's on 15 L is kind of something I want to know. Um Also whether the recent ABG um I'm completely right, whether he's in respiratory failure in this moment. But one of the other things that you'd want to be considering is whether with his background of CO PD, whether he might be a retainer and whether aiming for sats of kind of over 94 is is not helpful in him and is likely to do more harm. So, so ha knowing whether he's got a recent VBG or ABG can be really helpful for that. Um Yeah, and urine output. Um I want to know if he's passing urine. Um So whether he's got a catheter in whether they're accurately measuring it. Um So we can get a bit of a fluid status on him. His s are kind of low BP, high heart rate is kind of giving an indication of that. But urine output is the best way to measure um kind of fluid status. Um Yeah. So the other things you said is an X ray. So knowing whether he's had an X ray or information is really helpful. Somebody said about his meds antibiotics. And then also another really important thing is knowing his tap status. So respect forms are sometimes used in some hospitals. Some people use tap forms and that's just knowing whether patients for CPR, whether they're for antibiotics, whether they're for fluids, things like that, that can be super helpful um to know and it hugely changes what you're going to do. So if this patient is, is not for antibiotics, he's, he's likely just for supportive care. Then someone using a 10 is probably going to need to be palliated. On the other hand, if he's for R and for everything, then that completely changes your your kind of assessment of the situation. Um So the answer to these follow up questions are as follows. So the nurse says that his sats have now come up to 96 on 15 L. So that's reassuring. But we don't know whether he's a retainer or not. He hasn't got any recent VBG S or ABG S that we can see in terms of his medications, he's only on some Ramipril and some CO PD inhalers. He's had one dose of oral doxycycline since coming into hospital for query pneumonia. He does have a catheter but they haven't been measuring it accurately. So, um, we're not quite sure what is, what's happening with his urine output and he's not for CPR, but he is for all other things. So IV, fluids, IV, antibiotics and things like that. So, what do we want to do now, how high up would you prioritize this, this guy, do you think in your list he's using of 10? I'd say pretty high up. I would probably be, get, getting there pretty quickly. Um, if someone phoned me about a news, a news 10. Um, but one thing that I think I learned more during the, on calls as an F one is that one of the most useful things you can do is while you're on the phone to a nurse is, is to think of what they can do while you're getting yourself there. Um, often you're, you're finishing off a task or you're, you're on the other side of the hospital and you're not gonna get there for five minutes, 5, 10 minutes. So asking them if they can start the, the kind of the ball rolling while you're on your way there can be super helpful. Can anyone think of anything the nurse might be able to do whilst you're, you're on your way there? Yeah. Yeah, that would be very helpful to get ABG, what might they be able to do at the same time as they're taking bloods? Yeah. So we want a fresh, fresh set of bloods. A VBG, an E CG cos he's tachycardic is a really great idea. Um, a blood culture. Definitely. So now we're going down a bit of a sepsis six. And what else can we do while we're taking blood from somebody that might be helpful in someone who's got a low BP and is tacky. Yeah, get access. So please ask them to put a cannula in as they're taking bloods cos that would be a bit mean to stab them twice to put a cannula in and take bloods. Um And yeah, the other sort of things you can do is you can ask them to, to prep some stuff. So you could say I'm probably gonna want to give him some fluids. So could you prep a bag of Saline? Um and, and give him some paracetamol cos he's spiking and yeah, repeating s are super helpful. Um One of the other things I put on there was that if you're very wor if you're kind of in your first few weeks is an F one, I definitely would feel extremely worried about going to see a a news 10 on my own. Um, so often what you can do is say, please, can the nurse escalate to the med at the same time as I'm going over there. If somebody's really, really sick and you're worried they're not quite peri arrest that they don't want, they're not quite requiring, sort of a, to, to, to, but you're very worried about them, then you can ask kind of meet the med reg there and review them together. Um That doesn't always often happen in reality and it often takes a while to come and it's often helpful to have an initial assessment before you call the med reg. But um it's never a bad thing to do if you're worried and you feel out of your depth. So while you're walking there, um you often find as you're walking to someone who's using a 10, obviously you're very worried and you're probably very stressed, but there's things you can be thinking of as you're on your way there and some of the stuff can be sort of potential differential. So in your head thinking, ok, what could, what could be going on with this patient and what things is, are important that I do once I get there, can anyone think of what their initial impression is just off based off that phone call with the nurse? Yeah. So it could definitely be an infective cation of COPD sepsis. Yeah, definitely broadening it out a little bit. That's obviously the obvious one. is there anything else that kind of looking outside the box a little bit could cause shortness of breath, oxygen requirement could give you a fever. Pe? Yeah, definitely. And what sort of other investigations do you think once you get there you're gonna want to, to request or try to get? Yeah, you, you might want a C TPA. I think that's probably further down the list at the moment. I think a chest X ray first would be really helpful. Um And the other things I was thinking of was things like ABG. So the, the nurse might be able to do AE BG for you. Um But getting an ABG in someone who's short of breath can be really helpful. Um depending on what they look like when you get there. Um Other things you could think about are things like c to be, but that would probably be lower down my, my list at the moment. Um And I'd probably be chatting to a senior before I start doing things like that. Um So possible differentials. I've got down worsening pneumonia to sepsis. Um And, and just in my head, I'd be thinking what, what do I need to do if that's what I'm thinking. So I need to make sure that we're doing the sepsis six and we're giving him better antibiotics than this one dose of or dou that he's had if it's P EI need to make sure that I remember to check his calves, check if he's on an oxy and whether he's maybe got any other risk factors. Um Could it be pulmonary edema? That's an important thing to think about again, checking his legs when you're there, um listening to his chest and any kind of heart failure histories can be important with kind of any fluid that we decide to give him. Um and asking questions like whether your shortness of breath is worth when you're lying flat and things like that can be helpful. So just having those things running through your mind as you're getting, there can be helpful. Um And I've written down ABG chest X ray MSU just in case you're spiking because of another reason. So as part of your sepsis screen, often it can be helpful to not get blindsided by one co potential cause and doing an MSU could be helpful and doing a CBG as well. So he's a type two diabetic and making sure his CBG S are all right. So you get there and you take some, you hi take a history and you examine the patient. So the history from the nurse um often when you get to the ward and you asked to go and see someone who's sick, the first thing that's really helpful to do is just to eyeball the patient, make sure they're not kind of peri arrest and you should be getting in there straight away. Um but he looks ok from the side of the bed. So you go back and you go and chat to the nurse and get a better history of what's going on and the nurse says that. So he's come in after three days of being short of breath, um, a cough, a fever and he's been confused at home. So, whilst he's been in, um, the nurse has noticed he's gradually become a little bit more breathless over today. He, they lasted their jobs four hours ago and its that sort of borderline at that point. Um But now he's a lot more breathless from the patient. You can't get very much. So he's very confused. His A MT 44 is zero. So he doesn't know where he is. He's not oriented to time place or person. So he's, he's not very helpful, to be honest. So you go on to examine him. His news is now of eight. So it's improved a little bit. Um His respirate has come down a little bit and his SATS are up at 97% on 15 L. His BP is still low. His heart rate is still a little bit high. He's still confused but his temperature has come down as well since his paracetamol, his airway is patent. His um work of breathing is increased and you can hear some crackles on the left side of his chest. His pulse is irregular and it's kind of weak. Um quite thready when you listen at the radial pulse, his heart rate's 99. His heart sounds normal. Uh, but it's hot to touch. He looks quite sweaty and he's cold peripherally. Um, he's confused. Um, but alert and his CBG is fine. It's 9.1. His abdomen is soft, um, and nontender. His bowel sounds are fine and his calves are fine. So you are now kind of waiting on some of your investigations. Um, you probably have an initial kind of thought of what's going on, on, based off that examinations. Um, but you've got a few things that have come back. So this is his E CG and his BBg. So I'm gonna let you guys have a look at that. Um, for a little bit, we've been kind and put in what, whether it's normal, high or low for the PBG. Um, you, you'd obviously have the reference range on the actual BBg sheet. Um, but once everyone's had a look, if they could send a suggestion of what they think is going on based off those investigations. Yeah. Hopefully you can see them. A CG. Ok. Right. Yup. You guys got it. So the E CG, it's irregular and irregularly irregular. So it's, it's af what's happening with the VBG. Yeah, fab. So the ECG, um, shows new AF on the VG, it can be quite difficult to establish a respiratory status on a VBG. Um, the high CO2 CO2 does suggest that he's kind of retaining CO2, you're right. Um But often CO2 behind a VBG, just cos you're taking it from a, a vein, not an artery. Um So it's quite difficult to tell on a VBG, whether someone's acidosis is metabolic or respiratory. Um So what's kind of more helpful is just to, to see kind of the trend with a VBG. Um So we know that he's acidotic and that's bad and we know that his lactate is really high and that's bad. And that's also supportive of this sepsis picture. And it doesn't tell us very much about kind of respiratory status. So we probably need a, an ABG based off that to make sure that we're not missing anything else. Um What can be helpful is sometimes the bop um ABC on A BBg can tell you a little bit more um because that's sort of more of a chronic, chronic compensator. So if the bicarb is high, um that can tell you a bit more about whether someone's maybe retaining CO2 chronically. Um But I would say an ABG would be helpful in this situation. Um So going forward. So you've got this E CG that shows AF and we don't know that he has AF before um his BBg shows he's acidotic with a high lactate of 4.5 which is pretty high. Um And you've examined him, but you've not really done very much for him yet. You've obviously given him oxygen. But what what are you thinking? Now, just before your senior arrives, your seniors on, on their way, but you wanna come up with an impression and a plan before they arrive, cos there might be another 5, 10 minutes. What sort of things are you thinking? Yeah. Any suggestion for IV fluid to give? Yeah, I would go with that as well. So, we, we don't know of any cardiac history, um, in this patient it wasn't his past medical history. He doesn't have any signs when you were examining him of um fluid overload. So I would say we're pretty safe with giving a 500 mil at this point. If he was old and frail when you went to see him, I would maybe give 250 or if he had any kind of past medical history of cardiac. Um I'd stick to 250 initially. Cos you can always give more but you, it's harder to take away. Um But I think it would be safe to give 500 in this case. Um Anything else? What's kind of your impression? What, what do you think is going on? And there's a couple other things I'd probably put in my plan if anyone can't think of anything. Yeah, I would agree with those answers. So I think my impression would also be kind of respiratory sepsis at this point. Um Anything else you'd want to put in your plan if we go back and think about things like his meds, um, what we thought of PBG and maybe further investigations. Ok. So, like you guys said, I've put down respiratory sepsis. So, worsening of his left sided pneumonia is my general impression of what's going on. Um, he's also got new AF, which is probably secondary to sepsis. Um, but time will tell with that. So if you reverse the, if you treat the underlying cause the A AF should resolve. Um, so hopefully, by treating the sepsis, you would resolve the af um But that's kind of an important part. I would put in the impression often in impressions, it's just useful to say it, it doesn't have to be kind of a diagnosis. You can just say kind of what, what your impression is. So even if that's like clinically stable, um but increased short of breath in increased shortness of breath or something like that, like it doesn't have to be a diagnosis, but it's helpful to have an impression at the end of every plan you make. Um So in terms of other things, I've put in a plan, so give a fluid bolus, like you guys said, um to espi antibiotics based off your, your guidelines and always check the local ones. Um So we want kind of accurate fluid input output. That's part of your sepsis. Six is the catheter. Um So we want to make sure that that's measured accurately. So we can guide fluid management. We want to get an ABG and a chest X ray. Um Also you want to chase those bloods and the blood cultures that the nurse has already sent. Looking back at his meds, he was on Ramipril. You probably don't want to be giving him Ramipril at the moment. He's got low BP. He's probably got very vulnerable kidneys if he's in sepsis. So Ramipril is a bad idea. Um I would want a senior review. I often would write that in if someone's sick, that's a a go to in your plan um as an F one and then I always tend to write as well at the end of the plan to escalate if there's any further concerns or deterioration and pop your bleak number on there as well so that the nurses know where to, how to get a hold of you. So moving on from that, you implement those things from the um from your plan and you go and rereview him and that's in about half an hour after the fluid bolus is finished and he's had his initial things and his news is now three. His respiratory rate has come down beautifully to 19. His SATS are now 97% on 10 L. So he's weaned a little bit. His BP is 100 and 10/80. So that's come up and his heart rates go down, gone down to 79. He's also a febrile at the moment. So you fixed him. Um when you examine him. So, always go through a A to E again when you go back and rereview people, his airway is still patent. He's still got his left sided crackles. He's a bit warmer peripherally, but he's still dry when you look at his tongue and things, it still looks a bit crispy. His heart sounds normal. His pulse is regular and he's passed around 10 mils since you saw him 30 minutes ago. So often as a ballpark measure, you want people to be passing around 30 mils per hour. Um So that's kind of not quite enough. Um So he's probably still quite dry, but often it takes a little bit of catch up time for the urine output to, to catch up. But clinically, he still probably looks a little bit dry, he's still confused. Um So he needs to think a little bit about that and think about other causes of potential delirium, but he's probably got the obvious cause of sepsis and respiratory infection going on. He's still alert, which is good news and his abdomen is so soft. So you, you, you do that ABG that you've been thinking about and this is the result of the ABG. So I'll let you guys have a look at that and just have a think about what do you think might be going on. So the main thing that this ABG shows is that there's, he's a bit acidotic but only mildly. So his ph 7.33 which is mild acidosis. His lactate has improved a lot. So his lactates come to 2.8. So, yeah, that, that's right. He's got a, a kind of a mild metabolic acidosis picture. So he's got low ph with a high lactate and a high ano ano gap. Um He's also got kind of loads normal bicarb, which is in keeping with that. His CO2 and his oxygen is within normal range, if not on the bit of a low side. Um That kind of suggests that the oxygen therapy helped and it's probably resolving any kind of respiratory element that was going on. His normal bicarb is also very helpful to suggest that he's not a retainer of CO2. So you should be aiming for SAS above 94%. Um And yeah, serial ABG S and BBg is the most useful. So getting them repeatedly is what kind of things like it really look for. Um But that's kind of your initial impression of the ABG here are his X rays. So you can see, I'm not gonna ask you guys cos it's pretty obvious, but you can see that there's a worsening of his um left sided pneumonia from his admission to today. Um So that kind of fits with your picture. Um So kind of in summary of this first scenario. So he had respiratory sepsis um and his in his examination the second time round his pulse was regular. So his af was resolved post giving him fluids. He's still however, a little bit dry. So your, your plan following your second review might be to give him a little bit more fluids. Um, but a little bit slower this time. So maybe 1 L over four hours. You want to continue with antibiotics and paracetamol, continue accurately measuring fluid balance, wean his oxygen, but keep it above 94%. And then you might want to rereview and repeat the VBG to make sure that lactate is coming down in maybe around two hours. But that's subjective based on the individual who's reviewing. Um And again, always write escalate if any concerns and you might want to update the next of kin depending on the time um that you're reviewing this patient if it's in the middle of the night and he's improving and he's doing well. Um It's kind of a judgment call, but you might not need to overnight. But if he's, he's very sick and he's not improving, then that would definitely be on your list of jobs. Um So yeah, that was the first scenario. So when we wanted to get in the second scenario, now, if anybody has any questions. Cool, thanks Carrie. Um So the second scenario is a common one that you'd get on call when you're taking over the shift at the end, the end of the day, you, you've got the five, you're holding the bleep from five till nine. between the day team going home and the night team arriving to collect the bleep and your colleague on another ward phones. You up and says hi. Can I please hand over this patient to you? Um Please, can you chase some bloods for Miss Williams? She was missed off the phlebotomy ran this morning. So I've just noticed this and I have literally just sent her bloods. I'm going home. now, please. Can you chase them? Um So what sort of information do you think it would be useful to gather on the phone before your colleague goes home? Pop some ideas in the chat. Some of them will be similar to um previ the previous scenario. Yeah, perfect. Where are they? What's their number? Um Yeah, full name, date of birth hospital number or NHS number? Um Yeah, brilliant. Which bloods they particularly interested? Perfect. Anything they're worried about what bloods and white. Yeah, brilliant stuff. Um Carrie, do you want to fl onto the next slide? Thanks. Um So yeah, you got it. So some information about the patient um where she is, what are her details? When did she come to hospital? And why, why is she here? Uh What are we treating her for? Does she have any other medical conditions? Um And then is there anything in particular you want me to look out for on her bloods? Um Are you, are you worried about her? And also finally when did you send the bloods? Um just so that, you know, when to look out for them. So in answer to some of these questions, um she missus Williams is a 53 year old female. She was admitted yesterday with a three day history of severe nausea and vomiting. Um Your colleague tells you that as her white white cell count was normal on her bloods. They're treating this as a viral gastroenteritis and she's not on any antibiotics. Her admission buds showed that she was a little bit dehydrated with a mild ak I so they're treating her with some IV fluids. Uh in terms of her other medical conditions, she only has hypertension and some uh gastroesophageal reflux disease. Um An answer to what would you like us to look out for? Your colleague says, uh please, can you review her ene check her renal function is adequately adequately improving with the fluids. I'm not very worried about her, just look out for the bloods. Um One with the blood sent 5 p.m. just before I'm going home. Um Is there anything else you'd like to know that we haven't covered yet? Any follow up questions? Yeah, it's always good to ask her how, how actually is the patient like is she, does she feel rubbish? Is she feeling a bit better than when she came in? Um Actually answer that question. Your colleague says, oh, you know what she actually says that she's feeling lousy but I'm not too worried about it. He's a bit blase this col colleague. Anything else? Yeah, urine output. Very good. Um And whether she's confused or not. Fantastic. So uh she's, she was admitted with a bit of an AK I um and when A KS are particularly bad, sometimes urine output can go off quite dramatically. So, if she wasn't passing any urine, I'd be much more worried about her and might even want to go and clinically review her. Yeah, check the uh what medication she's on? Fantastic treatment so far, check the labs. We received the the bloods. Yeah, sometimes it's quite good if you have the online system. Um just to click whether the stickers have been printed. Um and whether they be received by that because you might find that actually they would never said at all they were just handed to an HC A who put them in their pocket and then actually went home and the bloods were never done. In which case you're waiting and no bloods coming back. So that can be quite helpful, particularly if you are not getting the results when you are expecting them. Um So yeah, what re medications is she? Is she on? Um my favorite acronym for medications in AK I is Stop the damn drugs. So, diuretics, ace inhibitors or um angiotensin receptor antagonists. Metformin and nsaids should all be held in AK I because all of them um can make renal function worse. Metformin doesn't actually make renal function worse on its own. But if you have a poor renal function, you're at a high risk of a lactic acidosis. Um, with Metformin. So you want to hold that one as well? Um, I'd ask her what fluid she's on, how quickly she's having it. Um, and whether she needs more fluids prescribed on the back of, um, a review of the bloods. Um, does she need a fluid review? And yeah, as uh who said it, somebody very helpfully said um is she passing urine? So, oh yeah. Oh I did well done. Um So it rolls around to 630 her bloods are back and this is what you see. OK. Any initial thoughts, what's jumping out at you there or what things are jumping out? Yeah. Perfect. High potassium. Yeah. Very high well done. Team. Nice one. Yeah, nice. Um So I've put in what her a her creatinine was it yesterday and also what her baseline creatinine is. So you can see that not only is she well off her baseline but also her renal function has deteriorated since yesterday. And um as you've rightly pointed out, her EGFR is low. What do you want to do next? Yeah, perfect. ECG calcium gluconate is you guys know this well done. Um We'll crack onto the management slide then. Um So yeah, al always a good answer is to go and review the patient and do an ABCD E um but very early on while you're doing your ABCD, you want to be getting an E CG and a VBG. Um VBG helpful just to see what um current potassium is as well. Usually the hormones are more reliable than the VG, but it's helpful to have a look at that as well. Um And to see whether she's got an acidosis because sometimes hyperkalemia can be associated with an acidosis and acidosis can drive a hyperkalemia. So it's helpful to see a Ph on the G um look up your trust protocol and hyperkalemia, they're usually pretty clear and pretty step by step. So, hyperkalemia doesn't have to be scary. Um Before you start your hyperkalemia management, I would recommend just giving the med a call. Um If you feel confident you don't have to say come and review the patient, but you can say just so you're aware, I've got a patient. She's 53. She's come in with a um ak uh on a background of nausea and vomiting for three days. Her potassium on her most recent blood is 6.9. I am going to do blood, blood blood. Are you happy? And they, if your plans sound sensible, they'll say crack on. Um it might be that they can offer a bit of remote support or they want to come and see the patient. Um So the hyperkalemia guidelines um carry, can you look forwards? Sorry, I don't know, I don't know where the button is on here. Oh, sorry. Hyper wasn't the next slide. Next slide was um her A to E so um she's got a user four. She has slightly high respiratory rate but she's saturating fine on air. She's a little bit hypotensive and tachycardic. Um and she's afebrile and alert. Um her at E A and B unremarkable C she looks, she still looks dehydrated. She's got quite cold hands and her capillary refill time is five seconds peripherally. It is two seconds centrally. So she's still confusing centrally, just peripherally um less good. Um Her pulse is regular and her heart sounds are normal and she has one cannula in situ, you ask the nurse, is it working? Um and you flush it and it's working fine. Um D unremarkable G CS 15 pupils are equally reactive to light and she's not hypoglycemic. Um And then on her VG um she's acidotic this um oh I haven't put the lactate on there. Um But her lactate is nor um only slightly high, let's say it's 2.3. Um So it's not quite high enough to account for her acidosis. You look through the rest of it. Her CO2 is also uh on the low side of normal. So there's a bit of respiratory compensation there. Her bicarb is low. So this is a metabolic acidosis um and this has a normal anion gap. So um it's not caused by added acid like, you know, lactic acid or um ketones in DKA. Um it's caused by a uh too little bicarb and this can happen in AK I when uh the kidney uh poorly excretes uh hydrogen irons. Um and or doesn't produce sufficient amount of bicarb, which is the function of the kidneys. So, she's got a metabolic acidosis. Um and that's probably contributing to her AK I as well. So that's helpful to know. So the next slide hopefully should be the management of hyperkalemia. Oh, it's not again, sorry. Here's your E CG. What are your thoughts? What can you see on this E CG? Yeah. Tall tea, tall tea, tall. T you've got it. Um So as you're rightly saying, she's got obvious signs of hyperkalemia on this ECG. So she's got those classic peaked T waves. She's got, um it's hard to appreciate on this g because she's quite tacky but she has got flattened P waves. Her pr interval is a bit long and her um uh QR S is kind of broad, bizarre, so low flat T waves, broad, bizarre Q Rx and tall tend classic hyperkalemia. So now you need to manage uh this is the hyperkalemia guidance from my trust. Um Look up your local one. They're all variants of the, of the same thing. So, um they first suggest doing exactly what we've done. So, the ABCD assessment and a 12 lead ECG um if there are any acute ECG changes like she has. So that's on the, on the left hand side, um you want to treat straight away with calcium gluconate IV. Um and that's just to stabilize the myocardium. It doesn't do anything to reduce the potassium in the blood, but it stabilizes the myocardium and reduces the risk of um dangerous arrhythmias. With the hyperkalemia. You then want to lower that potassium. So you give insulin and dextrose insulin, er dri um stimulates the sodium potassium pump on cell membranes and drives potassium into cells. So lowers serum potassium quite quickly and you give it with dextrose so that you're not going to make them hypoglycemic by giving them insulin. Um Once that infusions gone in, it goes in quite quickly every 15 minutes, you want to do another VBG to check that they've responded. Um Once you've managed to lower their potassium um by giving insulin and dextrose, you then want to help them excrete that potassium from their body. Um So the next stage of management depends on the course. So in her case, um oh sorry, just rewind a second back to um but if, if er if potassium is still high after that first round of treatment, you repeat. So you follow the algorithm and go back er ways to lower potassium from the body er longer term. Uh sort of after that initial management, um we used to use calcium resonium to lower um potassium that helps you exc helps the body excrete potassium. That's now quite out of fashion and I haven't seen it used in my trust this year. Um Lokelma um it's a potassium binder. That's a much more popular option. Now, um it variable availability and trust. So I would um I would follow the algorithm in your trust if they suggest Lacalma to help potassium to be excreted from the body. Um Start that you can do, it can be given for just three days, it can be given more longer term. Some patients on who have very bad d are always on a bit of leal because they're always at risk of becoming hyperkalemic. Um So, uh going further down the algorithm. In this case, our patient has an AK and is acidotic. So she's got two reasons for her high potassium. One is her kidney is not excreting her potassium particularly well at all because of her poor renal function and she's also excreting. Uh her um kidneys aren't excreting hydrogen ions particularly well, either and that's also driving the hyperkalemia. So, um you can help with the acidosis which um in turn, will help with the hypokalemia by giving some bicarbonate um as per your trust guidelines. Um it's then important to continue to reassess and check the VBG in a couple of hours to make sure that um potassium hasn't gone back up to make sure you don't need to repeat all this treatment. Um I already mentioned about the drugs. So stop. Um as well as the drugs that you should stop in AK I um, there are a couple of other uh potassium containing drugs that you should stop. So, er, the most, most common ones that we see around in the hospital are laxed, actually contains quite a lot of potassium and Septrin or cotrimoxazole that can cause a hyperkalemia. Um, and trimethoprim is one of the components of cotrimoxazole. So, um, it's, you should hold those medications and if they need an alternative, you can start one at that point. Um Yeah, great. Next slide, please. Carrie um Great. So um in summary, uh this lady has hyperkalemia secondary to acute renal failure with an associated metabolic acidosis. She's got an AK I stage three and she's quite dehydrated. So, after discussion, discussion with your med reg, you give her some calcium gluconate and some insulin dex treatment, you recheck her VBG post treatment and you go back to the start of the algorithm. Um Luckily after one round of treatment, her potassium fell nicely to 4.8. So you didn't need to repeat it. You then gave some IV bicarbonate as per the guideline. Um And then you treated her dehydration by giving her some IV fluids. Um I already talked about leukoma and then you want to hand over to the night team to repeat her V BDA bit later to make sure that her hyper hyperkalemia hasn't come back. Um Any questions about that case, I've just sent a little message because I realize we're almost at 8 p.m. And we've got one scenario left to go, which might take a while. So, um if you guys could just send a message to say whether you guys would rather keep going or we can skip to the summary and you guys can read the, the third scenario in your own time. Um Cos it's, we'll upload the, the slides and things afterwards. I've just seen the question about what is the Elma, the kel is an oral medication and it acts as a potassium binder in the gut. So it um dramatically reduces the potassium, you'll be absorbing and therefore you excrete more potassium in your stool so it can lower potassium. Uh It's, it's not used in the acute. It, it doesn't acutely lower potassium because that it doesn't lower serum potassium. It's a binder in the gut. But um for like longer term um to kind of excrete potassium from the body, it can be used cool. So I might just whizz through this last one very quickly. Um Hopefully it won't take too long. Um And yeah, we can just um people can leave if they need to leave. Um So this is the third scenario. So you've been bleeped about someone who started coughing up plots of brown grainy stuff and you've been asked to go and review them. So again, we're thinking about the sort of things you want to be asking the nurse on the phone. Um What are the things that you might want to ask? Does anyone want to send any suggestions? So this sort of stuff are the same that we've mentioned before? So, um you want to know patient details where they are things like that? Um What their obs are doing, whether they're worried about the patient, um, whether um this has just happened once, so they've just had one kind of coughing up from it, um, of brown stuff or whether it's happened multiple times. Um, have they opened their bowels at all? Um, you want to know, um, why they're in hospital and what their past medical history is and drugs. So, like you guys said, so these are the answers to those things. So it's a 67 year old he's currently using of 10. He's got a high respirate sat to 95% on air. His blood pressure's quite low. It's 67/43. He's tachycardic with a heart rate of 100 and 25. He's confused and he's, his temperature is 37.7. So quite borderline. Um, and yeah, they're very worried about him. Please come quickly and he has had two vomits slash coughing episodes over the last five minutes and he's just opened his bowels and it's quite smelly and tarry and black. Um, so the nurse is quite worried about that. Um, they came into the hospital because they had a fall and in terms of their past medical history, they've got hypertension, they've had an M I, in the past they've got type two diabetes, they've got heart failure and they've got osteoarthritis. So, what kind of things are you gonna be thinking of in terms of follow up questions based off those things? Yeah, you're gonna want to know the HB level. So the, the quickest way to do that is to get a VBG. But you would also want some formal bloods at the same time. So that's one thing you can ask the nurse to do as you're running over. And some of the other follow up questions that you might want to ask are things like whether they've got a cannula in. That's a really, really important thing in this scenario because that's probably the number one thing the nurse can do while they're running over if somebody's BP is that low is to get access and to get wide access. So to get kind of a green cannula in if they can or at least at least a pink, not a little blue one in the hand. And it would be helpful to know whether he has any alcohol history. These things are the sort of things you probably look at after you've run over to the ward and, and made sure he's, he's kind of not peri arrest cos he sounds pretty sick from that handover. Um, but helpful thing to think about and also what meds he's on and what his tech status is if he starts to deteriorate even further. So, the answer to those things is that he just got one blue one in. So you're gonna ask them to put another one in, he, in his clocking sheet. Um, it says that he drinks 10 units a week of alcohol. Um, if anyone wants to send, whether that's good or bad or, yeah, what do we think of that? His medications he's on Metformin, Lisinopril, Atenolol, Furosemide Dapagliflozin and he takes over the counter naproxen for his osteoarthritis. Um So again, if people want to send kind of ideas about what they think of that his um CPR status, so he's for everything. Yeah, his a alcohol says is fine. So he's taking his max 14 units. Um He's only taking 10, so he's not really got any alcohol excess. Um So he doesn't need, um, we, we're not going down the route of kind of variceal bleeding. Um So the next thing you're thinking is what can the nurse do while I'm running over? And we've already slightly gone over some of those things if you want to send some more suggestions, but we mentioned kind of getting a wide ball cannula into them. So in the antecubital fossa, if we can. Um, so we can get some stuff into him quickly and I probably in this situation, I'm not overly concerned about fluid overloading him. Um And much more concerned about the opposite. So I've been wanting, um, I, I'd asked the nurse if they could start fluids. Yeah, like you guys have said, so to start fluids as I'm going over there, if they could start a bolus, um, you also want a, things like an ECG, um, just because he's tachycardic, always a good, good idea to do that. And also when your BP is that low and you have that tachycardic, often it can, it can lead to things like um ischemia in the heart. So making sure he doesn't kind of have any secondary ischemia to all of this going on is really helpful. Um And S GS can be helpful with that. Um You also really want to make sure that when they do the bloods, they do a group and safe and the clotting, um because that can be really important and the BG, like you guys said to get a quick result, um Major hemorrhage protocol is definitely on my mind when someone bleeps me about this. Um you could ask the nurse to, to activate it on your way there. Um Often though the major hemorrhage protocol, I would say needs a bit more of a senior decision. Um Often you'd kind of, you'd get there and then you'd maybe activate it. But if you're, if they're, they're very sick per arrest, you'd definitely be asking them to put out kind of 2 to 22. And a major, he um, in this scenario, I would probably ask them to fast speak for med reg so that they could meet me there. Um, or if they were worried that the patient looks terrible, I'd ask them to put a 2 to 22 up often it can be really hard over the phone to make those judgment calls. Um, but I would say it's always better to, to kind of do too much so to put that power rest out when you didn't quite need it than to not put one out and you did need it. Um But yeah, it kind of comes with time whether you think it's appropriate or not. Um But no one would ever give you a while for putting one out if they it wasn't really necessary. Um So in terms of what you're thinking as you're running over there, what sort of things have been running through your mind? You guys have probably all mentioned this. So things like the major erg. So you're thinking this person's probably having something like an upper gi bleed, it sounds like from his um Melina with the dark tarry stools and the coffee ground vomit. Um It, it suggestive of upper gi bleed um in terms of what the urgent things you wanna be doing when you get there. Um The IV access is the main one. So if you get there and the nurse haven't managed, that is the first thing you're gonna want to do like as soon as you can and start those fluids and you're gonna wanna get your senior there ASAP. So making sure that they beat the, the med edge as well. Um, especially kind of, you can get advice about whether kind of putting out a major hemorrhage is, is um appropriate in this situation. But I would say it definitely sounds like it would be appropriate. So you get there, you take a history and you examine the patient and this is the information you get. So, um, they're a 67 year old. They've been admitted because of a 42 days ago, they've had three coffee ground vomit episodes in the last 10 minutes. Um, they've got no fever, no cough, no shortness of breath, no urinary or bowels, um, symptoms. They drink two unit, uh, 10 units of alcohol a week and they've been taking lots of naproxen recently because of a bad hip. They've got osteoarthritis in their hip in terms of the patient, they're a bit confused when you go and see them. They're not orientated. Uh, but they do say that they have some kind of tenderness in their epigastric region on examining them. They're still using highs, they're using the nine on their repeat obs high respirate SATS. So, ok, 96 on air blood pressure's come up a tiny bit of 70/53 post bolus and their heart rate has also kind of come down a little bit to 100 and 20 post bolus but still very high, still confused and his temperature is fine. His airway patent chest is clear. He's pale, he's got cold per freeze. His cap refills very prolonged. His pulse is regular but very thready and he's tachycardic and his heart sounds are normal. His G CS is 14 because he's a bit confused. Um but his um pupils are equal and reactive and his CBG S are all right. His abdomen is soft. So that's good. He's not peritonitic. Um but he does have a little bit of epigastric tenderness. His calves are soft and he's got no erythema or edema in his legs. So your initial investigations have come back. What do you guys think of this E CG and BBg? I'm also just gonna send the see the feedback form whilst we're waiting. Um, in case anyone needs to go, if they could fill in that before they go, that would be really helpful. Yeah. So a got it. So the ECG is just sinus tachy. Um So that's good. So there's no ischemic changes on there. Um in terms of the VBG, what's sort of standing out to you on that VBG. Yeah. HB is 56. So that's not good. It's like it's a bit high which isn't surprising cos his probably muscles aren't being perfused and then his tissues aren't being perfused cos he's got a, he's very hypovolemic with that HB at 56. Um So, yeah, like you guys said, sinus tachy on the ECG and very low HB. So your senior is on their way, they've told you I'll be five minutes. What do you want to put as your impression? And what would be your initial plan? Mhm. Yeah. So your impression is a jab lead and your plan, you want to activate the major hemorrhage protocol? Um Anything else that you might want to do the major hemorrhage protocol obviously gets your blood very quickly but not as quickly as you need it. Sometimes in someone with a BP of 50. Yeah, in the interim, give them fluids. Obviously, you want to um give giving blood for blood loss is the, the ideal situation, but you want to definitely be giving them IV fluid boluses while, while you're waiting for that blood to come. Um Other things that you can put in your plan would be things like making them nil by mouth, making sure you've got that access. Um In this case. So someone's mentioned Terlipressin, Terlipressin is something that you give typically in variceal upper gi bleeds. Um There'll be a really clear upper gi bleed protocol that should be in your local trust and always follow that. Um because it tends to vary whether people give IV omeprazole in upper gi bleeds secondary to kind of um peptic ulcer bleeds or so non variceal bleeds. Um In our trust, we tend to load with IV omeprazole. Um so always check your your local guidelines. But Terlipressin is something you give variceal bleeds. So in people with kind of chronic liver disease and it vasoconstricts your blood vessels. Um but it also means that there's a big risk if they've got peripheral vascular disease and things like that for the rest of the bodies and body and limbs causing risks of amputations and things. So it's a consultant decision with things like Terlipressin. So as an F one, you don't need to worry too much about things like that. And at this point, you've done your realistically as an F one, you're gonna get that kind and you're gonna start the Ivy flo bless, you might activate the major hemorrhage and your we is then gonna be there and those follow on decisions are gonna be very kind of much made by a senior, not by you. Um Another thing to note with upper gi bleeds, particularly in patients who might not be quite as hemodynamically unstable as this guy is to do apr exam, particularly if they've not opened their bowels and you don't know whether they've got Melena. Um that's super helpful to do before you put in the gastro reg um with a query, upper gi bleed. Um You'd want to get strict fluid input and output. So that's um putting a catheter in and you want to send formal bloods. So chase those to make sure what the formal HB is. Um You also want to hold all his meds. So he's on some risky meds in people who are hypovolemic and unwell. So DACA flows in. You always hold that in someone who's unwell because of the risk of euglycemic DKA Lisinopril. Not good in AK I and Hypovolemia definitely hold that Atenolol. You don't really want to be giving him Atenolol, um which is going to be bringing his heart rate and things down. Um It's giving you an indication at the moment of, of how, what his hemodynamic status is. Um So I'd probably hold the Atenolol naproxen, definitely don't need any more naproxen. His Metformin in people who are unwell again, lactic acidosis risk. So hold that and fosamine as well, you don't want to hold that. He's very hypovolemic IV antibiotics. Um Also asked about. So that is another thing that you give in variceal bleeds um but not typically in non variceal bleeds. Um So, but again, just check your local guideline. You don't need to really memorize these things. It's you just follow a guideline and, and knowing the things like your a to e is the important part and the follow on things from that you, you tend to have time to sort of look things up. So I just put a little few notes about the major hemorrhage protocol and other things and major hemorrhage. So, um when you, the major hemorrhage protocol is something you activate when someone's hemo are unstable to blood loss So if their hemo are stable but their HB is 60 you wouldn't necessarily have to put a major hemorrhage out. You would just be ordering them units of blood to cross match them. Um And it wouldn't be as urgent. You might want to phone the lab and say that HP 60 please. Can we get it a bit more urgently? But you don't need to put out a major hemorrhage call if the hemolytic stable, um when you put out a major hemorrhage, make sure that you know who the patient is, what the hospital number is, what their date of birth is, where they are in the hospital. Um They'll also want to take your number and your name and things like that. So having those things ready is really helpful. Um often when you phone for a major hemorrhage, there'll be set kind of available bundles. It'll depend on your local trust will get teaching on it in your induction week and things. But often you would need to request how many units you want or things like that or request a certain bundle. So that that might be that you need to request an initial pack, for example, which might contain four units um or it might contain some platelets and FP as well. So it depends on your trust and, and what's available, but you might need to, that's why it can be helpful to have a senior there with you to know what to request um in some hospitals when you put out a major hemorrhage, you, it sounds so formal and a big thing to do that you expect it to alert lots of different people. But in some hospitals, it actually only means that you get a porter that brings you lots of blood. So make sure that you know, in your hospital, what it means to put that out and whether you also need to be escalating to your med and things like that separately or putting a 2 to 22 out for a, for a met call separately um to the major hemorrhage and you don't just wait for a port to arrive with some blood thinking you're getting lots of senior support, some other things um about major hemorrhage. So we've sort of already covered this. So things like t depressin and Cipro antibiotics and for variceal bleeds. But that decision's made by consultants. Um If they're on anticoagulation, you will need to reverse that. But again, guided by hematology, nothing you really need to worry about. But something that you'd need to alert your senior to, if they're on warfarin or something like that, they'd need PCC, um often if somebody's hemo are clear and stable. So like in this guy, the thing he urgently is an O GD. So often the med reg will be phoning sort of the gastro consultant on call. If it's out of hours to come in to do an O GD and they would go for that O GD immediately after being resuscitated um in people who are clinically stable. Um then they normally just get an OGD within the next 24 hours. And in some people, especially on Gerry's ward, you might have to be pragmatic and OG DS might not be the best for the patient and, and you need to have that conversation with them. Um But yeah, just things to note. Um So that's the end of the session. Sorry, we've run over a little bit. Um We've just got a slide and kind of key learning points. Um So some of the things that we were hoping to get across were that just that on call shifts are just for urgent stuff. And at the beginning, you're gonna get handed over lots of things that probably you don't need to be doing out of hours. For example, I remember at the beginning of our F one, we were handed over so many MRI scans to chase out of hours, but MRI S are not done out of hours, so there's no point chasing them. So there's things like that you kind of learn on the job that are appropriate to hand over and not appropriate to hand over. Um Before you start work in your induction week, really, really ask all those silly questions that you've got on your mind. None of them are silly and they're all really helpful to know, knowing things like where to go for your shifts. Um What hours they are, what wards you're covering where you can find bleep numbers, things like that are so important and just make the first time you're on call a lot easier. Um Things like learning how to send bleeps and how to answer bleeps um is really important. So asking that in your induction week, um and knowing where to find your trust guidelines is super important as well. Um Some of the apps that are really, really helpful are things like getting B NF on your phone. There's Pocket Smart Doctor which I don't know if you can actually download that anymore. I think it might not be available, but there's, there's other ones, I think there's one called like foundation Doctor that's also really helpful. Um There's other ones like induction app which I'd really, really recommend you get. Um, it's one that you can log into the, the you log in and you say what hospital you're at and it has the bleep numbers for like everyone, all the med regs and all of that. So super, super helpful to have you on calls. Um MDC is really help for um different formulas that you might need it for. Um And my shift plan is just an easier way to look at your rota. Um So like Juliette said in her, but SBAR is super helpful for handovers and at the beginning, um it can be really helpful to just think those through and it kind of comes naturally with time as you use it more. But at the beginning, just thinking through, what am I gonna say for each part can be really helpful before you phone. Um having an organized jobs list, super helpful. We've already got kind of a a teaching on that last week. So go back and look at that if you want more guidance on that um common prescriptions. So things like adrenaline and anaphylaxis. Um, salbutamol there, things like that can be really helpful to just kind of try to get in your memory as soon as you can, but we all definitely have to check it all the time. So I wouldn't worry too much. Um, and to always stick you 80 you can always fall back on it and if you're not sure, um, what's going on, just write what you see in your impressions and that's good enough and get senior support and yeah, always look after yourself. I don't know if you want to add anything. Juliet. No, I haven't got anything to add. Um Thanks for doing the summer side. Carrie. Cool. Does anyone have any questions? No question is a silly question because we were F ones at the beginning of last year. I mean, we are still f ones, we were new F ones in August last year. So we've just done it. Ok. Well, um, if you have any questions, um, yeah. Do you get in touch. I think our email is all over um of um promo stuff or message us on Facebook or Instagram. Um Yeah. Thanks for joining. Thanks for participating. And uh yeah, come and join some of our other sessions. Have a lovely rest of your evening. You'll be fine as an F one, you'll be fine. You'll smash it.