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Is that live now? Perfect. So could you guys see the slides prior or should I go through that again? I'll just go through it quickly. But basically, I was just saying that um just if we go back to the first light, we're just saying that we're gonna speak about the on call shift and the structure and what to expect. And then we're gonna go through some scenarios and well, while you're on call, you're just only completing clinically urgent tasks like reviewing patients, unwell patients. And some of the tasks you're expected to do is reviewing unwell patients, inserting cannulas or catheters that nurses struggle with and requesting or reviewing urgent investigations. Um So urgent investigation, things like CT head to rule out stroke, for example, a chest X ray to make sure that um an NG tube is in the right place um for feeding as well as prescribing or changing urgent medications. So things like antiepileptics, Parkinson's meds, pain meds um and reviewing pain generally cause that's a common um common presentation that nurses will always bleep you about you in some shifts. It depends on the shift, but in some shifts you can um be expected to clerk new patients. And lastly, you are expected to update the patients, um the families of unwell patients. So for example, if the patient gets quite septic overnight or virus, you're expected to call their relatives and make sure they understand that this patient, for example, um is either end of five palliative or that, for example, you're starting antibiotics, but we're not gonna know how well they respond to it. So you're expected to do that rather than the nurses and for the day team. So that's their regular job. Your regular job, you're gonna be expected to review all patients discharge patients. So, discharging patients is non out of hour task even though sometimes it is handed over, but it's not routinely an out of hour task and you should not do it, especially if it's quite a busy on call, you should not be doing it. You'd also not be expected to review non urgent investigations. So if someone, for instance, is um handed over, for example, chasing iron or B12 things that can wait till the morning and be acted on, do not accept them. And I know it's quite tricky when you start your job because you don't wanna reject any um handover, but uncles can be quite busy. So you need to prioritize your jobs so you can accept it, but make sure that you explain quite clearly to the person handing over, that is very unlikely that you're gonna do it or chase it. And also for the day, team changing on non urgent jobs and sometimes collecting new patients and to begin with, you might be quite not comfortable or not as comfortable as you'd be with handing over or receiving handover to you with like initially, I wasn't sure what to ask when a person hands over to me. So a quick tool that I find quite useful is sbar. So with sbar, you wanna know what the current situation is? So for example, this patient, why were they admitted? What at what stage of treatment are they? For example, if they're admitted for query in to acquire pneumonia, did they start antibiotics or are they waiting for a chest X ray and then for you to start antibiotics? So you always wanna ask uh what stage you also wanna ask a bit of a background. Um So background in terms of what's been happening, but also their past relevant, past medical history. So for example, if they ask you to do a fluid review, you wanna know, have they got heart failure? Have they got a, is it prerenal? Is it uh for example, a hydrone hydronephrosis? So you always wanna know because that will obviously change management and the a team knows the patient best. So you wanna ask about that and you wanna know what is their current news? For example? So are they stable? Are they not stable? How urgently do they want you to see them. And with, if it's the day team handing over, you always wanna ask them, what is the plan from the day team? Cause a lot of the times the consultant have seen them today morning or the morning, um the same day and they put a plan in place and they only want you to just follow instructions. So it's always handy to ask, what would you like me to do? So for example, if this chest X ray is negative, what would you like me to do? Or if the CT head is negative, what would you like me to do? And we leave? So while your uncle nurses will leave you for a lot of things. It's always handy to ask the nurses how where they are about the patient cause nurses mostly are quite reasonable. And if they say yeah, this patient can wait a couple of hours or no, you need to see them straight away. So you get um a sense of urgency and always ask what's their escalation? So are they for RT U? Are they not for RT U? Are they for palliation only? And what was their previous news? And what is it now? Cause sometimes patients um the nurses will say, oh, this patient is using for example, a nine and when they, you ask them, what was their previously used? It'd be a 10 or a nine. So at this stage, you wouldn't worry too much and if you had a quick look, for example, they're already on tazocin and fluids. So you wouldn't be adding much to it. So that can go low in terms of your priorities. But it's still, if a patient is using quite high, I'd say still go around and review them. But if you're quite busy, that would be low down the list. And I think the most important thing with uncles is you being organized to make sure that you've got a shop's list. I always like to provide the page between where the patient is, which bed there, all their details. What is their past medical history? Why are they in the hospital? When? What job I need to do? And if it's urgent cause like in our hospital, once you start, your uncle is quite busy and you get lots of handover within the span of 20 minutes. So it's quite difficult to keep um track of what is urgent. What is not? So I always have got a highlighter on me or like just put a little star on the urgent ones that you need to do first. So it becomes a bit easier. And as always, if in doubt, always, always um escalate and ask for senior help. All the seniors are happy to help and they always say that it's better for you to ask for help early on rather than keep it later. So we're just gonna go through the general approach that you're gonna expected to do whenever you're reviewing the on the patient. So first of all, you're gonna receive the handover from the nurses, you can review observation. That's always the first thing you do. And if you're quite busy, but you still wanna see the patient, you can always see like give drops to the nurses. So for example, if they're saying they've got chest pain, so you can always ask the nurses to do an E CG take, let's take a drop, do A BBg until I come and see them and the nurses are quite happy to do that and it saves time. And while the pa the nurses are doing that, for instance, you can review the medical notes, you can review the medication, their blood results and other um past medical history and background and then you go see the patient. You do the A two E framework as virtual in med school and then you put a management plan and in some patients, you'd always wanna escalate or hand over to her next. And as always, don't forget the most important thing is clear documentation cause whoever is gonna come after you to assess this patient is gonna look at your documentation and build on it, right? So the eight way approach. So I think I'll give you a hint there. But can someone tell me, I'm pretty sure you guys know um all about it, but what does it stand for? And what's the first thing we check for, just put, just put it in the chart. Yeah. So first thing is airway patency. That's right. So the first thing is airway and you wanna make sure it is he and protected and how do you check that simple measure? So, a simple thing is just ask them how they are or what their name is or how they're feeling. And if they're speaking, if they're not making abnormal noises, then you know, it is patent and what interventions you can do in the airway, what things can you think of any idea what we can do in airway? Yeah, so exactly show through a simple maneuvers, head f chin lift or if you're a bit more concerned about their airway, they're not maintaining it. You can always use airway jun so or pharyngeal junk, nasopharyngeal junk and as an F one, you are expected to use those. So obviously, if their airway is not patent, you wanna get the cardiac arrest team. So double two, double two or um if there is an urgent medical team in some hospitals, you wanna get that. But in the meanwhile, you are expected to use that. You're also, if you're confident they always advise using an LPA as well. And a simple measure is oxygen, 15 L, non re breathe right next. What are we checking after a and you use, what would we do after we've ensured that the airway is patent? All right. So next thing we wanna see breathing. Yeah. So next thing we are we move to breathing. So that's just checking respiratory auscultating, per cutting. I'm sorry, it's my Alexa um and um you wanna just auscultate and percuss and some of the interventions we give um is we can do an ABG if they're on oxygen, you can do a chest X ray, which is quite handy uh especially as a portable one if you're example, where they've got pulmonary edema or they've got a cap, but also other things that you can give is nebulizers. So if you auscultate and they're quite wheezy. Um so you can give nebulizers or inhalers, for example, an asthma attack, right? Moving on. What's the next thing we move on to and what do we do in terms of examination and interventions? Yeah. So circulation. Yeah. So you wanna check the heart rate, the BP. I wanna listen to the heart sounds and we wanna check the pulse manually as well as cap refill and as I do as well, urine output in um in uh circulation just because it relates to the heart and perfusion and simple measures. You wanna get an E CG. That's the most important thing if, especially if they're tachycardic or you find that the heart sounds are a bit muffled cause it could be pericarditis. And here also you wanna put in a cannula, take some bloods and if you think the patient is going for ses, don't forget the pink bottles as well. We wanna get a Phoebe G um to give you a quick indication of lactate if you should start um sepsis six or if you should start fluid as well. And here you'd give a bolus of fluid if they uh are hypertensive. And as of here, I also uh put in a catheter if I need strict fluid balance if the patient is um septic, but I'd say not the policy of changes and not all septic patients need a catheter. It depends if they are um not drinking enough. If there are higher risk, then you put in a catheter, but otherwise you just put them in an input output chart. What, what's next? What do we do after C and how do we test for that? And what interventions we can do? So I have to see we usually do disability. So yeah, that is blood sugar is well done. So you wanna test the G CS if the patient is stable, usually we just go for off with, see in between. So a little confused voice pain and unresponsive. You wanna check their ps for an overdose, for example, opiate overdose, you wanna check their glucose. Um For example, if they're drowsy with your CS, you wanna check the temperature for sepsis and simple interventions is gonna be things like paracetamol. Give them some. For example, if they ha um hyperglycemic, you wanna give them some uh glucose, either dextrose glucagon. And if, for example, you're thinking opioid um overdose, you wanna give naloxone. So it depends whatever you find you treat with medication. But indeed, it's mainly medications that you get and lastly you everything else. So that's the abdomens. You wanna expose the calves, you wanna look for any signs of bleeding. Um And if you're worried about, for example, Apr bleed Melina, you wanna do APR examination as well. And here you also give um some of the intervention, either you do a CT ABDO, but that's, that takes a bit of time. So you need to make sure that the patient is stable before you do that or for example, in pr um if you suspect a Melina transam acid, if there is a bleed, if there is a DVT, you wanna give um um for example, Doxy or Noxin. So you wanna treat it right? So with that in mind, we're gonna go through some scenarios and I think hematologist is gonna take over from here. Perfect. Yeah. So um we'll start with the, the first scenario. Um So you've got a bleep um it's out of hours. Um So the nurse has phoned up and she's saying it's s au you very kindly said hi, my name's Fran, I'm the F one cover doctor. How can I help you? And the nurses let you know that they have a patient who isn't using a 12 and whether you can come and review him. Um, so obviously with the news 12, you're definitely gonna go review him. One thing I think I've learned with, um, time is that it's nice to ask, um, the nurses if they can do kind of a few things for you while you're getting, making your way over there. Um, so asking them to do bloods if you know someone's got chest pain, asking if they can do an E CG just so that when you get there, it's already ready for you and especially when they're quite sick, you're not then having to wait and spend a lot of time waiting for lots of tests to happen. Ok. So, um, he's a news 12. Um, and we've now got a bit more information so, uh, often as well. I like to just get a bit on the phone from the nurses too. Er, cos it's very easy to be like, yes. Ok. But just to get a bit more. So when you walk over, you kind of know what you're thinking and what to expect. So, um, the patient is Mr Singh, he's a 67 year old man who's day two post cholecystectomy. Um, so he's using a 12, you've asked what's triggering the news? So his respirate are 25 he's saturating 98% but he's on 10 L via face mask. He's tacky at 120. His blood pressure's 90/50 his temperature is 38.3 and he's confused Um, so what kind of things are we thinking? Be? No monster? Just put some things in the chat and he's a, he's a news 12. So, what are you gonna do when you, you're going to review him? But what kind of things you have in mind for? Maybe certain tests or things you wanna check? Ok. So, the, the things that would stand out to me is that postoperatively we've got a patient here who's quite, quite unwell. They're septic. So you'd wanna do the sepsis six. Exactly. Blood cultures lactate. Yeah, you guys are on it. Um, so you'd want to do the, the sepsis six. which does anyone wanna put that? What sepsis six is in the chart? Yeah. Um, and he's day two POSTOP and he's got a new oxygen requirement. So I'd be kind of thinking what could be, what could be driving this new oxygen requirement that he has. Um, ok. So does anyone wanna in the chat? I'm sure you're typing away cos there are six things to put, does anyone wanna put the what the sepsis six is in the chat? Yeah. Yeah. Yeah. Yeah. Yeah, perfect. Exactly. So, um, he's already on oxygen. So we're giving the oxygen. Uh, we want to, yeah, exactly. Strict input output. Potentially a catheter. We want to take blood cultures. He spiked temperature. The nurses are usually quite good at, um, especially at Musgrove where, where we work. Um, they're quite good at, if a patient spikes the temperature as part of the protocol, they, they will take blood cultures already. Um And at the same time, they'll usually take bloods, oil and a V VG. Um So we want a lactate, I think here, potentially just because um of the new oxygen requirement, an ABG could be indicated because it'd give you the lactate and then can tell you a bit about whether the patient's in respiratory failure. Um, what were we thinking about that BP? So it's quite low. Yeah, or, or just because they're, they're septic, you tend to drop your BP. So, uh what you'd wanna do is you'd wanna give them a fluid challenge. And one thing to keep in mind when you have, when you're giving a fluid challenge is just making sure to have a quick look at the past medical history. And as you can see, uh Mr Sings previously had heart or has heart failure. He's had, he's got quite an extensive cardiac history. So just thinking about how fast and how much fluid do you wanna give him? Cos you don't wanna tip him into pulmonary edema, which would make everything worse and then looking at the investigations as well. So, um, the one that really stands out to me when you're looking at the blood, this is C RP is raised as well. So I think this is all kind of pointing towards an infective cause he's septic. He's spiking your temperature, he's got a new oxygen requirement. Um So we wanna start him on some IV antibiotics uh as well. And if you guys don't have micro guide, I would download that before your vas shift. Um because that's really, really useful if we get the next slide, please. So this is just kind of doing what we're talking about. So, on examination, he's able to speak to us, he's talking in full sentences. There's no wheeze, no stridor. So um no er interventions are required and just in terms of sorry, just to go back to the blood loss. I think you always do worry about that, especially in postoperative patients, but that's why it's so important to on ABG or VBG just having a quick look at the HB and making sure that they haven't dropped their HB uh significantly. And on the previous slide, it was 100 and 25. So we're not feeling too worried. Um and the nurses hadn't mentioned that he was bleeding from anywhere but always something to keep in mind. Um So then we go on to B um of the AT E and so we're titr the oxygen. Yeah, ABG and a COVID swab. And I think now that we're moving out of COVID era, sometimes patients will have a new oxygen requirement and we'll all be scratching our heads. Um Your chest X ray will be clear and just remembering that it could be COVID and it's still, it is still floating around and going around the hospital. Um And you'd wanna do um a chest X ray because he has this new oxygen requirement. He's spiking temperature. Um He's got slightly raised white cells, high CRP. So just checking that um it, it just doing a chest X ray to look for the cause. Um So then we're going on to see. So we've discussed the BP, it's low. We wanna give him a fluid challenge. So we, we do a 250 mil Bolus just cos we're slightly more cautious in patients with heart failure. Um always making sure as well to examine, do a quick fluid balance assessment. So he's got dry mucous membranes, he's cold, peripherally, he's tachycardic, his blood pressure's low. Um So doing that uh also because of his cardiac history, always good to do an ECG as well. Um We'd put a cannula in because uh we wanna put a cannula in cos we wanna give him IV er antibiotics. Er, we wanna take bloods, blood cultures, VBG. And one thing I think I found when I'm dealing with a patient that I'm quite worried about um who's using quite high is that you often are asking the nurses to do lots of different things. Um and there is normally just one nurse who's able to help you. So just remembering as well to also help with doing these jobs um and kind of being systematic and making sure you don't miss anything. Um Perfect. And then he was confused, which is in keeping with being quite unwell. His GCS is 14 but his pupils are equal uh and reactive to light. We know he's febrile and we checked his glucose, that's fine. So we wanna give him some antibiotics and then his urine output is low. So the nurses have been keeping a urine output chart and usually, um especially in surgery, I'm working on urology at the moment. So I'm quite fortunate where usually there is a, a good year uh input output chart. Sometimes you won't get that lucky and no one's been recording it. So you won't know at all. There is a chart, it's not really been filled in. So it's difficult to say. But luckily we've got a great chart that's been filled in. We know that the urine output is 20 mils an hour. So we know that it's got reduced urine output. So we do wanna put a catheter in and have that strict input output chart. Um Also important as well. I think in heart failure patients because you're always cautious with giving fluids. So if you know exactly how much is going in and how much is going out and you're doing fluid reviews, I feel that you can confidently give the right amount of fluids. Um he doesn't need. Uh and then on inspection, just looking to see if there's any abdominal distention because he is POSTOP um because checking he is peritonitic. Um his abdomen on examination was soft, non tender, making sure to check his calves, which they said before you want to do a urine dip and an MSU as well. Just because I if the chest X ray comes back clear, often another source of infection commonly is urine um and just making sure to monitor urine output closely. Um So that's our chest x-ray. Anyone wanna tell me what they're thinking? No, it's ok. Um So you can see, I don't know if sounds arrow will come up on the screen. No, but you can see the, you can see consolidation. So if you see that um, white kind of wedge kind of shape on the right side. Um So you can see consolidation there. So it's all in keeping with um a pneumonia and cos they're in hospital, it's um hospital acquired pneumonia. So hap and so what you'd want to do is go on to micro guide and go to severe hap and start them on the, the antibiotics that your trust recommends. Ok. Next slide. So, yeah, exactly. So the septic, we know the cause we've started them on the antibiotics. We've given them a fluid challenge. Don't forget as well to reassess. So we wanna recheck his BP, see if that's improving. Um And we want to make sure that we're documenting that. So it's if improving, continue your management, if they're continuing to deteriorate you've kind of done as much as you can and you really, at that point, need to call your senior. And it's really useful that you've done this review cos it saves your senior time and you've action things as well so that they can then escalate it as appropriate. Um, it's also really good to just check their, um, TE form. Uh, so they're treatment escalation plan form, which kind of tells you whether they're for CPR, whether they're for noninvasive ventilation, whether they're for it. So, you know what their ceiling of care is as well and that's useful to tell your senior. So that then you kind of know where you're at. Um And how far you can escalate the patient. Um So you want to make sure you document all of this as well that your seniors aware and if they're unwell, you want to hand over to or you're coming to the end of the shift, just hand over to the next person because especially then using a 12, the nurses will probably bleep them later on in the night. So if you've given them a heads up, they can be like, oh yeah, I know what's happened. I know what's been done and I know what results or whatever are outstanding. So yeah, se E PS is six just a summary there but, but we've discussed it any questions about what we said so far. No, and if you think of any just pop them in the chat and then we can, we can answer them at the end. Yeah. So we just moving on to the second scenario. So I see you again cause you know why not? And this time they've got a patient who has had a fall and they're very drowsy and they're asking you to come over and review her. So you accept that. So on the way there, you're on the phone to them. What would you like them to do until you get there? What simple investigations can help you? And what are you thinking in terms of your differentials? What do you wanna rule out? You just put some answers in the commence? So what is the first thing that pops into your mind when you are a patient who had the fall, especially if they're elderly? Um And they're very drowsy now. Yeah. So intracranial hemorrhage and ECG is a good idea as well. Yeah, cause it could be a cardiac cause that cause the fall head injury. Yeah. So what things would you ask the nurses to do something very essential to ask them to do until you get to the patient? Especially if you've got another sick patient or you're dealing with another septic patient, vital signs, well, then vital signs and especially neuro ops just to make sure that they're not getting more and more confused and more and more drowsy. So you get there, you've got a bit more of history from the note. So this is Missus Jones. She's a 72 year old female. She was admitted two days ago with a lesional bowel obstruction. Her current news is a respiratory is a four and because of her respiratory of 16. So is fine in the air. She's a bit tachycardic with heart rate of 92. BP is ok. She's a febrile, but the only thing is she's only responding to voice at this point. So you went, you have a quick chat with her. She's unable to give you a history. She's quite unresponsive except if you shout at her. The nurses tell you that they found her on the bottom floor. They did not see the fall, but it happened around 30 minutes ago and they picked her up and held her back into bed. And other than that, no new symptoms have noted her past medical history. She's got hypertension type two diabetes and she's on lots of medication including antihypertensives, statins, amLODIPine, Metformin, um some inhalers and GTN as well. She lives alone. She's a nonsmoker and she does not drink alcohol. You have her look at her bloods from yesterday. You find out that she's got a good renal function. C RP is 42. Sodium is 136 PSA is 3.1. So it's just a bit on the low side. So you may think about replacing that 92 and inr 1.0 white cells is 10 and HP 109, right? So what is the first thing you wanna do and bear in mind that we're gonna go through a two E so in any emergency situation, while your uncle always the first thing you wanna do is at ae assessment. So what are you gonna do? So if you tell me I'll give you some results and then we can see what we can do with that. So as we mentioned, we're gonna go through airway first and we said that she's only responding to voice and she talks at you. She makes, she says some incomprehensible words. She's not making sense. You don't, you don't hear any wheeze or Stridor would, what would you like to do if anything, is there any interventions or would you move on to be? What do you guys think any thoughts? Are you happy with her airway? Yeah. Well, be I'd say I'm happy with her airway. Nothing to do. Really? So I'm just gonna move on, moving on to her breathing. Really? You um auscultate. Nothing, there's nothing there. You can't hear any sounds per because nothing is been there as well and you palpate her trachea, no tracheal deviation. Are you happy with that? And Harry s that's N six. So A. So would you say she needs anything here? How are you moving on? I'd say from this point there's nothing happening in breathing. So I just move on. There is very low chance that she's got infection or asthma that's causing her to be drowsy. So I move on. If you're worried that for example, if her past medical history is saying for example, that she has got COPD and she's, for example, on oxygen, then you might be worried that she's retaining carbon dioxide, then you'd get an ABG. But in this lady, she's not on oxygen, she hasn't got CO PD. So you wouldn't do anything, you just move on, you move on to see her heart rate is nine too. She's a bit tacky BP. 1 14/6 7. So that's fine. She's a bit dry but she's still well perfused and you listen to her heart, normal sounds no other sounds. You have a feel of her pulse, normal rhythm and character. So she's not in af would you want to do anything at this stage? Yeah. So fluids definitely. Yeah. So you wanna put in a cannula get some fluids? What about that? Tachycardia? Would you want to do anything about it? Someone earlier said an ECG. So I think in this case, I'd get an ECG just in case anything, for example, um a stemi or Anstey that's caused all these symptoms that caused the fall or another cardiac reason that caused the fall. For example, atrial flutter, even though you pick it up in the pulse spot. Um, it can show you a bit more about the heart, for example, T wave inversion um all that. And as always, you wanna put in a cannula at this stage just in case you find something later on and you wanna get some bloods including blood cultures cause we haven't got to see yet. So we don't know if she's got, she's spike in temperature. But looking at this, looking at her news where it seems like it's less likely that it is an infection. And also you wanna get a VBG just to make sure that her lac her lactate is not spiking high or for example, she's not hypernatremic or um severely hypo um Kalem and that's what caused the fall as well. Next, you wanna go into D so she's responding to voices. We said she's a febrile G CS 12 E 3 B3 and M six and eye s are reactive and equal. And you do a glucose, you find it 1.2. What would you like to do? Yeah. So how do you go glucose on this lately? So we've got three options with glucose. Which one do you think is the most suitable in this lady? So we could do that with Leuko just around her gums. But I'd say because glucose 1.2 is quite low. Yeah, I'd say IV as well. So 1.2 is quite low. She's symptomatic. So you wanna act quite quickly. So you would give dextrose or glucose um 10% uh 200 mils and you wanna give it relatively quickly. So 15 to 30 minutes and you wanna monitor the BMS quite closely because she is also a type two diabetic. And after you give it out with ac you always, whenever you do an intervention, you can go on to the other category but do not forget to come back and reassess. Cause for example, if you've given her dextrose and she hasn't responded, you can give another bag of dextrose. But in the meanwhile, you need to think about other causes that can make her drowsy other than the hypoglycemia. And lastly, that's her examination. So you find that they run out for 40 miles per hour, which is fine. You find that tube drainage, no signs of injuries and no bony head or um spinal or limb or pelvic tenderness, abdomen is soft, mildly tender and calf soft and nontender at this point. What would you like to do any interventions or are we happy with that for now? Yeah. So what did he say? CT? So we could do? Yeah. So we could do a CTA. Yeah. So a CTA. Yeah. So if you're worried that she hit her head, so because it might be unwitnessed. So in this stage, I'll just monitor the urine output and just be aware that while you're doing these intervention, you're always reassessing. So obviously, if she does not respond to the glucose or the dextrose that you've given IV, I'd say CT head is the first thing um, and you want it quite quickly just because it could be a bleed. But looking at her history, she's not on any anticoagulants. She is not tender all over her head. So I, if she's responding to glucose, I'd say you're up for several hours after and if she's not back to herself and completely conscious and um oriented time place and person within 2 to 3 hours, I'd request that CT head. So it's always good. So with, with these patients who are responding, it's always good, good to give them 2 to 3 hours just to make sure that you are doing the right thing. Obviously, it just not responding to treatment. CT head would be the first thing I'd do. Um Just to make sure that we're not missing a the but with these patients who respond and they become more stable, it's always good to give them a couple of hours and then the day team, if she deteriorates further, they can always request Act head. But to be honest, if you do request act head at this point, no one would tell you that. Um why did you request them? Cause you've got every right to request them, given that she had an unwitnessed for. So this was a case of false secondary hypoglycemia as we said, you do at e and after every intervention, you wanna reassess, see if the patient is responding, if not responding, think of other, other differentials, think of more investigations and you could always go back to your eight week if the patient is deteriorating, always, always aspect your saying. And sometimes so in our trust, if it's a, if the patient is using five or more, you need to alert your. So just alert them that this patient is ill, I'm gonna go, um, see them and for now you don't need to do anything, but I might need to call you a bit later. It just gives that a bit of notice and time. But also if you're quite unsure about anything, the pa the knows that you're going to see an ill patient. So they're gonna be available um, to answer any of your questions and help you um with reviewing this patient. So I'm not quite sure if you can see that clearly, but that we're gonna put the sides up anyway, but that's a quick hypoglycemia overview. So if the patient is mildly hypoglycemic, they're not confused. They're not drowsy. You can give them a snack, you give the, give them um orange juice, you can give them she or just a carbohydrate snack if they are mildly drowsy or if they're just a bit confused, but it still can. Um So they, they're just confused but not drowsy, then you can try the glucose gel around their gums and that helps a lot. Uh But if it's our patient, they're quite confused, they're quite drowsy. They're only responding to voice. So you wanna give IV as the first line. If they've got all the access, if they do not, you can give Im Glucagon but just be aware that Im Glucagon do not give it to no, no mouth patients or if they've got um hepatic failure. And in terms of V ri so if you're reviewing these surgical patients and their nail by mass, so they put them on V ri, just make sure to pause the V ri until the CBG S are around four or more. And then you can restart the V ri um obviously with already monitoring of their CBG S and with V ri S, it gets a bit tricky. So you, I'd say in that case, you'd wanna um inform your ho to come and review them with you and give you advice on how to manage the V ri. And after you manage the hypoglycemia, you wanna give them a longacting carbohydrate. So a piece of bread, some milk, something to stay in their system um or a meal if they're due, if they are due a meal. And I think next slide is just the full overview. So in our chart, we've got a nice perform for falls, but generally what you wanna do or in my um what I usually do is just head to toe, head to toe. So I make sure that they're not confused for instance, what your G CSI, make sure to test their um reflexes a quick cranial nerve examination, especially the ocular nerves and just the eye nerves. So, um make sure there is no nystagmus or blurring cause that would probably, you'd want to see t head if you find any of that, uh, ask them about nausea, vomiting. Um And then you move on to, I just like to listen to their heart. Just make sure that they're not in new af um have a feel of their tummy test their reflexes, make sure they're not hyperreflexia um and have a um a feel of their spine, make sure they're not tender anywhere because that could be a fracture as well. Make sure you have a feel of their hips and uh and test power in upper and lower limbs as well as tone. Um cause that can tell you a lot about because it could be a stroke that could lead to the fall as well. So in that case, you'd need an urgency to head as well as an um a a review to rule out a stroke um and start treatment and um if you do request any investigation, make sure to follow them up and update the nurses because a lot of the time the nurses are not quite sure, especially if it's a full, quick, full review and the easy one and the patient, for example, you just order um an x-ray of their arm cause they're quite tender around their shoulder joints. Nurses would want to know the result just cause it helps them, for example, mobilize the patient or not. So, always communicate the results of the investigations to the nurses. And obviously a good thing to do is lying in standing BP, especially in the elderly because a lot of the time they've got push hypertension. Um, and it's always good to have a look at, at their medications, make sure they're, they're not on lots of hypertensives that can cause that. I think that's the end. Have you guys got any questions about this case or anything? You'd like me to clarify? If not, we'll just move on to the next case. What is the map called? So a me, I think that's in some trust there is like um a medical team for which is more so in our chart, we don't have it, but they're for more um emergency situations. So they're not a cardiac arrest team, but they're a medical team for urgent stuff. So you can call them just if you're not quite sure if the patient does not respond quite quickly to your treatment, especially with drowsy patients cause they can lo lose their airway quite quickly. So you can always put that out by now our trust, we don't have that. So we always put, if we're worried about airway, we'll always put a double two, double two call. Um and the team is always happy to come and review this patient with you. So just moving on to the next scenario. Ok. So the third and final scenario, um, it's Sae bleeping you again. Um, and they have asked you to review a patient with chest pain. Um, so what kind of questions do you think you'll be asking the nurse on the phone? Yeah. Um, often though. So the nurses will do the best to tell you what the patients told you told them, but often with a full Socrates, you'll have to don't be shocked if you don't get a fantastic um kind of history from um from the masses. Yeah, exactly. So uh reason for admission, the observations, what the patient's complaining of. So they could probably tell you kind of the site and the character of the chest pain. FMH. I don't know what that acronym is. Sorry, I might be have, it might be a bit of a blonde moment for me. Um And perfect. Um And anything you might wanna ask the nurse to do. Yeah, perfect. If you were asking them to do bloods there, any specific bloods you'd want them to do? Yeah, exactly. Perfect. Great. We go to the next slide. Yeah, exactly. Yeah. ECG um drops. Perfect. So uh we've got a bit more information. So um Mr Matthews is an 81 year old gentleman. He's day three post total hip replacement. So he's using a nine. So you've asked for the observations and that's because he's scoring because he's um got a respirate of 28. He's saturating 95% on a 4 L4 L of oxygen. He's tacky, uh, with a heart rate of 100 and 12. His BP is a little low at 96/54 and his temperature is fine at 37.8 maybe, slight, slightly getting, um, to the threshold of a fever and he's alert. So we've got a bit of a, a history, the nurse has told us that he's got this new central chest pain and shortness of breath that started today, but he's not had any nausea or vomiting, any dysuria bowel changes. Uh, in terms of his past medical history, he, um, has high BP. He's had a previous M I and he's type two diabetic. Uh, in terms of his medication, she told us he's on multiple medications. Um, social history. He lives alone. He's a nonsmoker. He doesn't drink alcohol and the bloods that we do have his latest bloods, uh, from earlier. Uh, so EGFR is 77 uh CRP is raised 98. His sodium's 100 and 34. His potassium is 4.1 creatinine, 92. Inr is one white cells, 11.2 and his HB is 100 and 23. Um, so we are going to review him. So, um, oh, it's come up with, with the answer there. Um, so I'll be reading out what the next, what the findings are just. So we don't get the um, spoilers on the screen. But for our way, we've, we've, it's been given to us. So his resp rates are 28. He's saturating 95% and four least we know that he's able to talk in full sentences. There's no audible wheeze or Stridor. So like it says on the screen, we're happy to move on from a to breathing. So I will read out the findings. Um, and if in the chat guard, you can tell them what you think the intervention should be. So we know the respirate is 28 we know his saturations. Um on inspection, there's no audible weasel stridor as we know on palpation, he's got no tracheal deviation, percussion is normal, you're auscultating and you have reduced air entry in the right base. So um what in, what do you think we want to do? Yeah, perfect. So you wanna um do a chest X ray? Um Why are we doing a chest X ray? Yeah. ABG S. Yeah, exactly. So we wanna, exactly. So we're thinking pneumonia, we're thinking pneumothorax. He's got this chest pain. Um And we wanna do an ABG Yep and COVID swabs also on there. Uh Perfect. So, and we've got him, we're titr his oxygen, he's saturating. OK? On 4 L at the moment. So we're happy with that. Ok. So we then move on to see. So his heart rate's 100 and 12. His BP is um 96/54. Uh, we've inspected him and he's got dry mucous membranes. He's warm and well perfused. Uh, we've felt his pulse, uh, he's tacky but it's normal rhythm and character and on auscultation, uh, normal heart sounds. So, for c what interventions and in investigations do we wanna do? Yeah, exactly. So, we wanna give him a fluid bolus, um, because his, his BP is a little low. Perfect. Uh, any investigations we've already mentioned one of them. Um, yeah, exactly. Um, yeah, exactly. You guys, yeah, you've got it. Um, so one do, uh, 12 lead E CG. We've asked for some bloods as well using CRP, uh D dimer. A tricky one. I don't tend to, to order them as often as, um, maybe I thought I'd be doing. But yeah, um, considering CTP, um, ECG for sure. Um, and Troponins as well. He's had previous Mr S, he's diabetic. It could be, um, it could very well be, be an M I, um, have that query blood cultures. He's not spiking really. So he, um, could be appropriate depending on what you see in front of you. Um, and a VV gi would tend to do, he, he's POSTOP check a lactate, um, and, um, take it from there. Perfect. So, um, the next slide if we could go to that, please. So we have an E CG, I'll give you guys a second to, um, look at it and then once you guys have interpreted it. Um feel free to put your findings in the chart. It doesn't need to be the whole thing. Um And don't worry about putting the wrong thing in. I know ECG S are super tricky and I take a while to look at them. Yeah, it is, it is sinus tachycardia. Um um So perfect. Um Normally, so we're checking it regular which we can see it is we can see he's tachy um looking for T wave inversion or ST elevation ST depression. Um And it's not there, it's sinus and it's tachycardia. Perfect. Next slide, please. Well, actually, no, not next slide back by, back by back. Hopefully, none of you guys saw that. Um So the next um slide. Um so we have done C went down to D so he's alert, we checked his temperature. It's 37.8 g CS is 15. Pupils are um equal and reactive to light and his glucose is 7.6. Uh Are there any interventions of further exa um um investigations? Well, are we happy with, with that? Yeah, I'm, I'm happy with it. Um I don't think there's um anything in that's alarming me there, he's alert. Um GCS is 15 glucose was within range. So I'm happy to, to move on and, but we'll keep it on the slide and then uh finally e so his um urine output is 35 mils an hour on inspection. There's no abdominal distension. He has, um, a catheter in situ uh draining uh, rose hematuria with no clots on palpation. His abdomen is soft, nontender. Uh right calf is swollen, tender and erythematous and bowel sounds are present. So, what do we think could be happening? Yeah. Um, so urine output is, is, is ok. It's slightly, maybe slightly low but not too bad. Um And yeah, exactly. DVT. So the, the right calf is swollen tendon and erythematous and he is post uh quite a big. Um Oh, so we would want to, it says it on the slide, but what would we want to do? Kind of putting everything together? What do we think he has? He's got the, the oxygen requirement, the chest pain, sinus, tachycardia and ECG right swollen calf. Yeah, exactly. Pe. Um And so we think he's on a pe so the two things kind of from an f one point of view that you wanna do are in terms of management. It has one of them on the slides. So you wanna start them on treatment Dose Taxane and then you want to order something, an investigation. We said it earlier as well. Yeah, exactly. CTPA, uh anticoagulation. Um And we want to, if you go to the next slide, please. So, uh we think it's a pe um we want to order a C TPA and then I would, if this was me on call, I would call my senior. I'd let them know what was going on, fill them in. They'd probably be like, yeah, perfect. Um, because we've got them on the right treatment and we do the CT PA and if the CT P came back negative, then we would, uh, take him back to prophylactic dose. Um, Clexane. But if not, we would continue, um, we'd be making sure that currently he's cardiovascularly stable, but we'd make sure to continue to monitor him. Um, and we'd hand over and kind of follow him appropriately. So just a little bit about pe so investigations, uh we've kind of spoken about this um but it's, it's all on the slide uh for you to see. Um and there's a little bit there about enoxaparin BTE dosing guidelines re remember as well guys to always check um EGFR because that affects the dose that you're giving. Um So always make sure you're checking that and to check their weight too. Cool. So summary. So just to wrap it up, if you guys have got any questions, just put it in the chat while we'll do that as well. So while you're on call, you're on completing quite urgent tasks and reviewing acutely unwell patients who cannot wait to the next day. So you can always refuse to um accept a handover if it's inappropriate. So don't be scared, especially at the beginning or if you don't wanna refuse, it just always make sure you just tell the girl or whoever is handing over that. This is a low priority and you're only gonna do it if you've got time, it's always um, handy. Obviously, just before you start where to find out information about oncle shifts. Usually they're gonna do a briefing at the start of your F one or your irit tells you. What's the structures? How many hours are you gonna do? Where it, where the handle we happens? What's expected of? You had to answer some believes as well as um your seniors who are they. And it's always good at the beginning of the shift to take their numbers rather than be so believes and numbers just because some people respond quickly to phone calls, need to know where to find your trust guidelines. So especially your first nights during first on call shifts, you're quite nervous, the things that you know, will go out of your head. So it's always up to you just to know where the guidelines is just to make sure that you're not missing anything. And also to help you with any um treatment plans that you haven't um done in a while. Some useful apps will be enough. And I think we spoke about micro guide induction up is quite useful if you wanna leave other people. Um I found the smart doctor or the foundation. Um doctor app is also quite useful. Gives you an overview of, for example, if it's chest pain, it gives you an overview of what questions to ask what to look for and um quick treatment plans for things like a CSP E. So it's quite useful. It's on the phone. So you can always look at it while you on the way to assessing the patient me calculator is always good and my shift planner is just so you don't miss any on call shifts because it's quite easy, especially if you've got two different rotors. Um to be a bit confused. When are you on call as far as quite useful at the beginning when you're first trying things just to make sure that you've got all the information when you are receiving or giving a handover, make sure to be organized. And while you're on call, you might get handed over a lot of jobs, you don't need to finish them or you can always hand over to the night team, but just make sure you do the most urgent jobs and always, always, always acutely on while patient use a two week, it'll help you be more systematic, but also make sure that you're not missing anything. And it helps with the I find that that it helps with differentials a lot. You either ruling in or out differentials because you're going through um the systems questions. And lastly, always look after yourself. If you're getting overwhelmed during oncle, always be your seniors. It's quite common at the very beginning to find yourself struggling to keep up with the jobs or getting a lot of leads from the nurses are not quite sure how to manage all that. Always speak to the seniors. They're very, very supportive at the beginning of the year and they are always happy to take some of the work of you. Is there anything else I missed on the? No, I think. Um, that's great. That's, yeah. Um, everything you said, I agree with, it's really easy to find it quite daunting, but just remember that no one will ever shout at you for escalating your concerns and it's way better to escalate something that was maybe not as major of a deal as you maybe thought it was or the patient wasn't as sick as maybe you thought it was. It's way better to do that than to, to miss someone that is quite unwell. Um So just feel empowered that you're, you're making the right decision. You guys, you've been in med school, you've gone through it, you know it. Um So yeah, and can a C TBA be done out of hours? Yes, it can um in different trust. It works differently in our, you can request that the CT is there. You'd need to phone telemedicine who do the reporting and get a radiologist to vet it that, that can be done um out of hours. Um And can we start anticoagulant? Yeah, you can start if you start them on um treatment dose and then kind of just wait for C TPA. S, but most trusts especially ours is very good with, with getting it done kind of as soon as they, they reasonably can. Yeah. Um, and just with anticoagulation in terms of, um, if a patient just make sure to check their platelets and get an up to date platelets just because one of us, um, I've heard that one of, um, our colleagues started a patient on anticoagulants where they're very low on platelets. So it's not the best thing to do. So if you worried that about their platelets always escalate and that way the senior can get the CTPA done quicker and you can hold off the anticoagulant starting the anticoagulant until you've done the CP uh CTPA. If you guys haven't got any more further questions, could you please fill out the feedback form? It helps us to plan um the next sessions and we do sessions every Tuesday from 7 to 8 or 815 cause we're running late today. Um But we would really appreciate if you fill in the feedback forms and join us for the next sessions. Thank you.