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This webinar is the first episode of NSTSSFP's webinar series, focusing on the clinical interview. The speakers are all successful candidates in the London SFP program and they will help participants gain an understanding of how to prioritize each situation, use imagination to optimize the situation, get more information, the A to E assessment, differentials, and how to escalate appropriately. Join the interactive session to get tips for succeeding in the clinical interview and participate in a research project.
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This webinar is designed to prepare you for the SFP interview. It includes mock interviews given by a variety of successful applicants, top tips for interview day and opportunities for Q&A.

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Learning objectives

Learning Objectives: 1. Understand essential clinical assessment processes and activities when presented with a vignette. 2. Appreciate the importance of prioritization based on patient safety. 3. Demonstrate understanding of the different forms of information gathering during clinical assessment. 4. Execute an A-E approach for different clinical presentations. 5. Appreciate the importance of appropriate patient escalation.
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Computer generated transcript

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

Oh, so Monta, you're gonna introduce the series and they'll be like, now everyone else introduce themselves. Yeah, exactly. Yeah, it will, it will flow. It'll be fine. We're, now we're live now. We are. Thank you, Lucas. Hello, everyone. Good evening. Thank you very much for attending. Um, so this is the NSTSSFP webinar series. The first episode or, er, webinar is going to be on the clinical interview. My name is Monty, I'm one of the SFPS at Imperial on vascular surgery. Uh, and I'll just let the other guys introduce themselves. Um, hi guys, I'm Maria. I'm an F one, I'm doing academic surgery and innovation SFP at Imperial College as well. Hi, everyone. I'm Lucas. I'm a final year medical student at Edinburgh. Uh, and I'm one of the education officers for Ns CS. So as the true academics that we are, we've woven um, a small research project into this webinar. So Maria's going to post a link to a questionnaire for you in the chat. Now, if you could please kindly follow that link and complete the questionnaire in the next minute or so, while we patiently wait, then that would be much appreciated and I'll probably just repeat myself again in about 30 seconds like a robot for anyone who is newly joined in that time. Um, while we wait, if anyone wants to ask questions at any point during the webinar, feel free to just comment in the chat, we may not be able to address them immediately depending on sort of what stage we're at. But, er, if not then we will certainly go back to them at the end. It's nice for this to be interactive. It makes it more entertaining and probably more valuable for all of you guys. So, if you've just joined in the last 30 seconds, please follow the link in the chat that Maria has kindly posted and, er, just complete that very short survey and we'll get going in the next few minutes and just the third and final time. I'll say this. If anyone's newly joined, please just follow that link in the chat and complete the questionnaire and we'll start in about one minute. Where do you want to sing a song or tell, tell a story joke. I feel like we need some intercom music or something. Like they haven't elevated some what? Sorry. You know, like the music they have been lifted. Oh, yeah. Yeah. Yeah, we should have, we should have too late maybe tomorrow. Um, yeah, feel free to post suggestions for music for tomorrow's webinar. Ok, guys, I think that's probably been enough time to complete the questionnaire. So um thank you again for joining. I'm just gonna share a presentation. Here we go. So can, can everyone see? Wait? Yeah. Can everyone see that? OK. Oh Maria, can you confirm that I'm doing the correct thing? Yeah, we can see. Yeah, thank you. OK. So this is the clinical station. This webinar is run by National Surgical Teaching Society. It's quite a good undergraduate slash postgraduate trainee run society. Puts out some really helpful material for surgical applicants. Have a look at the website. It's all on there and there's a CST interview series that's coming out very soon as well. We're also sponsored by MD U. So it's an indemnity supplier. It's a good company. Uh You guys are all at this stage of becoming junior doctors. Pretty much. Your choice for indemnity is MD U or MP S MP S is free but MD U costs 10 lbs. However, I would genuinely recommend it because they have a really good helpline and they also send you a nice Oxford handbook, which is worth about 40 lbs anyway. So promo for MD U over um straight into the webinar. So this, it's important to just mention this webinar is specifically focused at the London SFP interview, er all of the interviews you'll see and er the panel are successful candidates with the London SFP. I think regardless of which unit of application you're applying to, there should be some transferable information and it should be quite useful regardless. But maybe the specifics on the structure of the interview might not be as relevant if you're not applying to London. So you're gonna be probably given wherever you apply. I assume you'll probably be given a clinical vignette at some point in the interview. So this will give you information, describing a situation where you are a junior doctor and it will require you to verbally respond to the situation and describe your subsequent actions. So, um but er, so just to sort of validate that what I'm saying isn't complete garbage. I scored full marks in my London clinical interview. Er, obviously, there's multiple approaches you can take, you'll see different people take different approaches, all of which are equally er good. But er, so, so don't what, what I say isn't necessarily the only way, but I'll just give tips on how I personally approached it. Er, so I'd say first read the entire vignette very carefully, you don't want to miss anything. Um There might be one big obvious case that needs a dressing like an unwell patient, but there might be something else hidden in there like an angry relative, er, hiding round the corner. So it's very important that you get a full appreciation for the entire situation. If you do have multiple issues to address such as an unwell patient and an angry relative, you want to prioritize, of course, and that prioritization should always be based upon patient safety So if you've got two unwell patients, then the patient who's more unwell, who's deteriorating faster is the one you need to see. First, if you've got one unwell patient and then sort of an ethical issue, then it's important to, again, see the unwell patient, but you also can optimize the situation. So don't feel sort of trapped in um, anything that's not on the vignette, it doesn't mean that they've been mean by not providing you information, it means they've been kind, by allowing you to imagine what else might be happening. For example, if the vignette doesn't explicitly say that you're on your own, then you can assume that you may have colleagues. So you could say that you would like to recruit one of your colleagues or seniors to visit, to address the other situation while you address the first situation, for example, and finally use your imagination. Um I don't really know what I'm meant by. That sounds a bit cringy, but, er, essentially just you can create things. So you can imagine if there's an HC a nearby, they can do the OS for you. If there's a nurse nearby, they can do the bloods for you. So you, you can really think outside the box. Um, and that also makes you sound like someone who understands the hospital and how the MDT works together. So once you've, er, you've assessed the situation, you've er, prioritized hopefully correctly, then you're probably next going to be approaching an unwell patient. So again, you want to imagine this is a real life situation. It's not an OSI where you're sort of inexplicably alone, dealing with a G CS six. Um You can imagine this is actually a real situation. So describe how someone would realistically behave in real life. For example, if the situation is close by and that you can uh you can attend it quicker if it's further away or you're called on the phone, you might want to gather more information over the phone that moves on to the next point. So you want to always get more information that can be from a handover from a colleague. If the patient's being referred to you by a nurse or from D for example, you can get information from the patient themselves. Of course, although that wouldn't precede an assessment, particularly particularly if they're acutely unwell, you can get information from hospital notes. If they're available, you can get information from relatives or neck of kin. If a collateral history is needed. I've written a MP L. That's just an acronym that I personally use. It stands for allergies, medications, pregnancy, past medical history and last meal. Those are all things that are quite important to establish early on in the assessment because they will obviously affect a lot of the steps within the A two E er you want to get your observations in early. So some people remember um their observations during the A two E, obviously, you can do your respiratory rate stats in B your heart rate, BP. In C personally, I like to say that I would request for an HSA or a nurse to do all of the observations immediately when I attend the patient. That means firstly, you won't forget any of them because you've already asked for them straight off the bat. But also just again, shows that you're thinking like an actual doctor. And instead of just a classic OSI slightly unrealistic approach that we unfortunately are taught in medical school and recruit colleagues to assist you. I've already mentioned that several times. So here's the A two E, this is a table, a prompt table that I created in the preparation for my interview. Again, this doesn't necessarily need to be what you use, you can create your own or approach it however you want to. But for me, it just made sure that I didn't forget anything. I actually spoke continuously for about eight minutes of the 10 minute clinical interview before the interview was asked any questions, I just spoke confidently and clearly unbroken and they didn't interrupt. So I assume they felt that what I was saying was appropriate. Er But obviously, as well as doing the assessment, it's important to kind of verbalize the differentials you've got in your mind because as well as seeing that you're doing a very comprehensive and thorough assessment, the examiners also want to know that you're, um, sort of narrowing down your differentials as you go. At least if you can, if you genuinely have no idea what the differentials are, then just go ahead with a comprehensive assessment because that's the best you can do. And always remember some of the sort of the less common ones like, uh, pr testicular exams, a pregnancy test if it's a young female with abdominal pain, for example, um, it's very good to have the blood tests that you would perform for various presentations memorized. So there aren't, there's a discrete list of presentations that could realistically appear. Er, for example, you might have reduced GCS, chest pain, abdominal pain, vomiting, pr bleed, that's not an exhaustive list. But if you memorize, er, which blood tests you would order in pretty much every scenario, then that allows you to quickly reel them off because it can be quite hard sometimes to think of all the different blood tests that you need and that may sound tricky. But actually, if you narrow it down, there's probably only about six different groups of blood tests that you would need to memorize. Finally escalation. So, escalation is very important. This is assessing your competence as an F one, which is the level that you'll start at when you begin the SFP program. Um, obviously, if you can, if you feel confident, assessing the patient and commencing initial management yourself, that's great. But it doesn't negate the requirement to escalate appropriately. Er, you've, of course, got the medical reg or the surgical reg on call if, er, depending on which ward you're on, er, who, who would be the first point of contact. But here is just a list of some of the other people you might want to consider escalating to bear in mind that who, if you're escalating to someone else on this list, you should still always inform your own registrar, er, because it wouldn't be appropriate to sort of go around them. They should always be aware of any acutely unwell patient and you can even notify them right at the beginning. So don't feel as though er, escalating to your senior is sort of copping out or saying that, you know, you, you're, you're, you're now beyond your competence. You can always say I would escalate to my senior at this point and then just continue with your assessment. Um So finally the completion. So it's again, just to wrap everything up thinking of it always as a real life situation. Once the patient's managed escalated, whatever it is, there's always more left to do. So you can hand over to colleagues as appropriate document what's happened because you probably didn't have time in the acute assessment, uh admit them if needed, chase up scan results. Uh If you've ordered a chest x-ray, although sometimes in sky will get handed the report immediately in real life, it's not gonna happen uh within two minutes and uh things like reporting notifiable diseases is another one just sort of icing on the cake. Finally, a lot of the situations will also throw in an ethical scenario to handle at the same time. Again, usually it's something that should not, should be addressed after the clin the sort of acutely unwell patient. But I'd advise it's very useful to have a clear protocols in your head. You want to be quite familiar with the Mental Capacity Act when it comes into practice, how to use it. Same with the Mental Health Act also when it's appropriate and necessary to disclose information, for example, to the police or to guardians, or is it safeguarding guardians of safeguarding? I forget the name now. But er, how to deal with challenging behavior, how to manage complaints and also skills of diff difficult communication. So things like taking patients into a side room, calming them down, bringing colleagues if necessary, getting them a drink, even things like that, it does sound good. Makes you sound like a compassionate holistic carer. So that's the brief run through complete. I'll now start to play the, er, I'll stop showing this and I'll now start to play the interview recordings. Um If we could send the link for them to read through the uh the vignettes, please. And while I load up this recording or maybe I'll send, ok, so if you follow that link, then that should take you to a Google document with er lots of vignettes, you can use them to just follow along as we play these recordings. OK. So um SDF 1 a.m. U um it just this scenario, I've got two patients that I would need to assess and manage. So firstly, a patient that has reduced consciousness. A second patients agitated and trying to self discharge. I think in general, when deciding which patients to review first, um I think I would like to treat as using a quick ABC D approach in my mind. So by first patient has a reduced consciousness that could very, very well, just mean an airway issue because if they um have dropped their consciousness below a certain level, there will be airway compromise and that really means that it's an A issue. So it's something quite urgently uh quite urgent that need to sort out. Um My second patient uh obviously would not be safe if they were to leave hospital, give medical advice. But I think at the moment, um the air is not an issue because they always talking to us. So I think um really, I would like to see the first patient with reduced consciousness first. Um And in the meantime, we'll just get the HC A to just quickly tell me things like observations of new score of my second patient and also to convey to the patient that we're just coming to see him shortly. Um And if possible, could you just wait a little bit more to see a doctor. So I think that's my initial prioritization. OK. That, that sounds very reasonable. So um having decided you're going to visit the 27 year old female patient. Uh how would you then assess that patient? So I think in assessing any sort of unwell patient, again, it's the ABC D approach that would just make sure that I cover my basis. So starting the airway, which I think would be the most important here. I'm just going to talk to the patient. Um try and rouse the patient to see um if they're able to answer me, if they can obviously talk about things like snoring. Then I would say that the airway is patent. Uh at this point, I also do a quick a mental calculation of what the GC score will look like. And uh if I suspect that that's a really low GC score, let's say eight or low. Uh and really the need um airway support. So I would put out a crash call um just to get in the anesthetic airway support the rest of the wider sort of intensive care team as well to support the un well, patient. I think in the meantime, just uh I will try things like airway maneuvers, head to chin lift just to keep the airway open. Um And also uh uh that, that would help um and just moving on to next bit ill, then try to assess be for breathing. So um I'll look for um the pattern of breathing, feel for things like tracheal deviation and obviously auscultate lung sounds as well. And look, I'll look at the respiratory rate, the saturations and um the patients desaturating. I'm gonna try and start them on 15 liters of oxygen and by a non relief mask, I think at this point, it's quite valuable to do an arterial blood test as well just for us to understand what the acid balance looks like like. And also um what sort of guesses they have and elected as well just to pause you there, Helen. So it's a very comprehensive medical assessment you're doing. Could you tell us about what differentials are going through your head when you attend this patient and how you might gain further information to try and guide those? Yeah. So I think there are lots of causes of why someone might have a reduced consciousness and that, you know, as I approach a bit, I'm just going to try and ask about the patient's history and background and the reason for miss, if possible, if, if that's not going to be available, then the other sort of differentials in my mind um would be things like um a neurological cause. Um um like um a bleed, for example, or space occupying lesion in the brain. I'm also thinking about endocrine causes things like hypoglycemia. Um hypo hyperthyroidism which can all lead to crises with and reduce consciousness just thinking about overdoses of, um, medications, whether it's IIC or taking medication. And I, I just want to look at drug chart to have a look at, um, medications that have been given and look at the patient's own sort of medication list if that's available. Absolutely. So, if you look through the patient's notes, you see that she's come through Ed and they've documented, uh, an clock that mentions that she is a known user of heroin. She denies using any heroin this evening. However, the nurse tells you that she did leave the hospital for about half an hour and return prior to becoming drowsy. So if you could go back to your assessment, um and you can continue where you left off, uh and just think about what else you might be um addressing and focusing on. Mhm Absolutely. So, um knowing that the patients uh an opiate user and possibly has um taken some opiates in the, in the last let's say hour or so, um there is a chance obviously that there's an opiate overdose and that is a big cause of reduced consciousness. So I think that uh assess for that. I will also just remember to um look at the respiratory rate because there could be respiratory depression alongside, uh just look at a pupil to see whether they pinpoint in size. Um and to quickly reverse that I'll just ask for naloxone to be given because um really that would give us a very quick answer to whether there was a possible opiate overdose. And as part of that, that brings us onto the circulation part, we just need to make sure there's good intravenous access that we can give that naloxone. Um So too large can and obviously just move on to as things like um the the cap refill, whether they peripherally shut down and auscultate the heart sounds, get an ECG done as well. Mhm. Ok. Thank you. And um, so here we're suspecting that it could well be an opioid overdose, given the history and the presentation. But of course, there are other causes of, of this presentation. So, are there any additional investigations that you might want to think about to rule things out? Yeah, absolutely. So as uh as I mentioned earlier, we've got neurological causes that I need to think about. So once the patient is stabilized, um and safe enough to get transferred to AC T, I'm going to try and book that. Um Also, um I'd just like to uh assess their pupils to see if they're equally reactive to light and whether um there might be some um weakness or paralysis on one side as compared to the other, which could point to, again, a neurological cause uh in terms of endocrine causes, I just want to get a capillary glucose measurement done quickly. Um because hypoglycemia is a easily reversible cause of reduced consciousness. Um And as part part of um getting intravenous exercise. I'm obviously gonna send off a series of blood including things like electrolyte levels. Um and also um thyroid function because all these things that point to where this underlying cause is. Absolutely. So, um if you've performed uh these assessments you describe and also, as you mentioned previously, the HCA has helped you by doing a full set of observations. Uh The respiratory rate is noted at seven and um the heart, the ECG is normal sinus rhythm, the heart rate is 60 and oxygen saturation is 95. Currently on room air, you note that the pupils are pinpoint um and how would you then react to the situation? So this um I would say strongly points to it, an opiate overdose is causing the reduced consciousness. So the, as I said, the, the sort of best thing and fastest thing that I can do to reverse is is to give naloxone. Um So I'd like to ask for an intravenous um injection of the naloxone uh two mg and to get that given as quickly as possible, um I know that the half-life is really short and that it is a really fast acting drug. So really within um I say half a minute to a minute, the patient should produce a response to that. Um If that's not sufficient, I just also repeat a dose of naloxone. But again, if then the patients not responding to that, then I need to start thinking about other differentials. And you mentioned previously imaging of, of the brain, the CT head, I think you said would you order a CT head for this patient? So I think that's something that I'll have to think about a bit later on in the acutely young patient, they're not going to be safe to get transferred or to sit in CT scan. So um I need to just make sure they're clinically stable. We ruled out other differentials before we can get a CT sorted out. Mm And uh you've approached this situation as an F one. and you've performed an assessment, you've started initial management. Is there anything else you'd like to do? Absolutely. I think um in any unwell patient, um it's so important to just have the wider team to support you as well. So like I said, if I think um there's a potential for um rapid deterioration of airway support, then that's a double two, double two call to get in anesthetic airway support the critical care team as well. Um But if it, if we've not really reached that level yet, then I could put on me call just as a medical emergency to get um the medical team here and to get seniors in my medical team um involved as well. And I think I just want to also make, keep in mind that um the other sort of staff members on the water could help me as well things like um the nursing team as well as also um other therapists that have interacted with this patient potentially know a bit more history about this patient. Great. And just finally, uh you've got this other situation happening at the same time, an agitated patient trying to leave who's known an excessive alcohol user. Um everything's addressed with the first patient. You put up the me call, the the medical registrars is now controlling the situation. How would you like to approach the second situation that you correctly prioritized as being less urgent? So in terms of the second patient, uh first of all, I just need to ensure that it's safe to approach the patient. If there's a risk of danger to either the patient themselves or to myself or to other patients, I think I just need to make sure that um I've got, I've got security involved and that it's a safe situation. Uh But let's say once I approach the patient, um I would just like to start with um just being really uh with some good communication skills, being really sensitive and empathetic and using verbal de-escalation just to speak to the patient, understand their concerns, their side of the story, why they're trying to leave. Um And um at the same time, I'm going to try and explain myself, I explain why it's unsafe for them to leave by, it's against medical advice for self discharge. I'll just touch on things like an alcohol withdrawal, which could lead to really severe symptoms like seizures and delirium tremors. I'd just like to also bring up things like thiamine deficiency that the patient might have and that this lead to long term damage of the brain encephalopathy. I think, ultimately sorry to interject the patient's decision to leave. How would you establish whether or not that could be respected? Yeah, absolutely. So, uh in my conversation to patient, I just want to assess the capacity of the patient as well. So um the four pillars will apply in the situation, whether they can understand information tain the information, weigh up what I've just told them and whether they can come to the physician and communicate that back to me. Um If any of these um four pillars are not met, then really the patient doesn't have capacity and in someone who doesn't have capacity, it's up to um the team to make a, a best interest um decision um and given the risks of um leaving the hospital, like I mentioned earlier, the really the best interest decision would be to keep the patients inpatient for alcohol withdrawal and further management. Um But I think if we go down that approach, we just need to make sure we use the least restrictive approach, possible things like garble de escalation before we do anything else. And also just complete the appropriate deprivation of liberty, safeguarding and make sure that's sent off um to the to the Right. Um, safeguarding team. Yeah, absolutely. Thank you very much, Helen. Thank you. We'll, we'll finish that. Thank you so much. Ok. So I think Helen did really well there. I'm not sure if I mentioned already that all of these prerecorded interviews, the, the interviewees or the candidates are actually successful SFP applicants specifically in the London Deary. So, er, they all perform really well and it's great to see how they sort of interpret the questions differently in their own way. Someone's asked what is a Met Call. Um, and so Elaine has asked what to Met call. Alexandra has already answered a medical emergency team call. Er, exactly. So essentially, um, it's an emergency call that you can put out in a hospital. I think most hospitals do have this, er, in place. So someone who's not arrested, otherwise they would of course merit an arrest call. But if they are acutely unwell and deteriorating, er, a medical emergency call can be put out either due to a nurse or doctor concern. Er, but I believe often if the news score, the national early early warning score um, is above six so seven or more, then, er, that would automatically merit a medical emergency call. Er, that's certainly the case in a lot of trusts whether that's a national universal rule. I'm not sure, er, everyone will know what you mean if you say emergency call in the A LS Jar has said in the A Ls handbook, there's a criteria for particular hobbs for a Met call. Would this be something we're expected to memorize? Yeah. So again, I think it's, it's over six, I think is, is usually an automatic, er, me call, the, the national early warning score. The news obviously developed and validated for sepsis, but it's actually applicable to pretty much any acute deterioration and it's used as such, um, widely. So I wouldn't worry about. There are rules like news of three as a doctor within an hour. News of five is a senior decision maker within two hours or something like that. I wouldn't worry about those things so much with regards to this interview. The main thing is when to call your call, your reg if the patient is unwell, um, put out a emergency call, if you're concerned about them deteriorating and put out a Perret or arrest call, if they've got an airway issue or their BP is tanking, or there's a problem that you think could quickly result in their d either death or extreme um, unwellness. Yes. Ok. I think that's all of the questions. So we will move on to the next interview, which is Maria, who's, who should I play next? Does it matter? Maria posted me so I'll play, you can play whoever. Ok, I'll play Johnny next because he's next on the list. Ok. Well, thank you very much. That's the end. You will ask the c questions. Thanks very much. Hi, Johnny. Thank you. So, moving to the clinical scenario. Have you, have you read through the abstract? Um Yes. Yeah, I think I did. Yeah, great. So could you start off by telling us how you'd approach this situation? Sure. So um as an F one, my utmost priority is always given me patient safety as accordingly, I would want to clinically sort of prioritize the two calls that I've received. Um though there is a concern about bedsores, um uh at present, what I can see is that there's no acute issue in terms of airway breathing or circulation. Um So I'd likely want to assess the four patients for patient first because there could be issues, for example, with head injury or bleeding. Um That being said, I'm a member of the wider team. So there are things I would do for the other patient. I just ask the nurse to take a set of observations and to believe me again, if things deteriorate or if um anything changes, they become more worried, but the falls patient, I'd want to speak to the nurse who's contacted me. I'd want to ask for a full s a handover. I'd want to get a full set of basic Abbs and get the notes and drug chart ready. And as I was walking over, I would be thinking about my top differentials in terms of causes for the fall and things that I'd want to ask. So, for example, seizure, um any head injuries. And also I'd want to be thinking about um I guess the patient prior history and if there's anything that I need to particularly rule out, um when I arrive, I'd want to ask for, I do a nurse and hea to help facilitate my assessment as well. Great. So, uh when you do arrive at the patient, um what are the specific questions that you or say, sorry, say you see the patient uh on still on the ground when you arrive, how would you address that? Sure. So with any acute assessment of a medically unwell patient, I want to take an A T approach. So I'd start by assessing the airway. I try to get a response from the patient. I'd like to see if they can talk. Um I'd have a look for any, if I see if they can vocalize, if they can vocalize, then I'd be happy that the airways patent. Um But if they weren't, then I'd want to have a look inside the airway to check for any obstructions. I'd want to have a listen for any other noises such as Stridor, such as gurgling, which could indicate indicate some kind of obstruction. Um And I'd want to respond accordingly. So if there was secretions, for example, blocking, I'd want to suction them. Um I'd, if there was any issues, I'd start with basic airway maneuvers. If that didn't work. I definitely want to uh 2222 and get some anesthetic support. If I was happy, the patients vocalizing, I then move on to assess their breathing. And the patient is, is speaking loudly in disjointed sentences that don't make sense. There, there's no evidence of compromised airway. The nurse tells you that the patient is diabetic on insulin. And this is what midway through your assessment at the point where you were just describing. OK, so I use some information. However, I think I need to go by clinical priority. So I will then move on to assess breathing, but I'm happy with the airways patent. So I'd want to look for some observ uh some sort of basic observation markers. So I'd want the oxygen saturation and to assess their respirator as well. I'd have a look for any signs of respiratory distress um and work increased work of breathing any cyanosis peripherally. I then want to have a listen to the chest in all zones for air entry and listening for any added sounds such as crepitus, um cos or, or crepitus. Um And I'd want to have a feel as well of the trachea to assess the deviation um chest expansion bilaterally. And I'd also want to percuss. Um So, depending on my findings, I would then consider some interventions such as a portable chest x-ray or an A BG if I was worried um and any oxygen support that might be required. Hm. Ok. So now that you've uh so I'll give you some results. So the respiratory rate is 15, heart rate is 80 oxygen sats 96 on room air. Ok. Is there anything else that you'd like? Um in terms of the breathing? I think I'm happy with that. It doesn't look like they have an increased work of breathing based on the spirit rate. The saturations are, are healthy. Um Do I hear anything on the chest? When I have a listen, the chest is clear, chest is clear. Ok. I think we're happy and I, I don't think there's anything I'd need to add from the respiratory point of view. I'd then move on to assess their circulatory status, which is, I think, well, probably what I'm most worried about with this patient. So I'd want their heart rate, their BP. I'd want to get at this point. I, I think it wouldn't hurt to assess their temperature as well to see if there's any element of infection or sepsis, which could be um contributing to the, as a cause of the fall. I'd want to see how they look generally. So, are they pale? Are they well perfused? Um are they warm peripherally? Um And I'd want to assess their JVP as well and any obvious sources of bleeding. Um I guess I'm just looking at them. I there's no evident source of bleeding. Ok. Uh But you do see the uh urine on the floor and it is foul smelling bo smell. Ok. So I think max, so I think it's reasonable to, to investigate um possible urinary tract infection as a source of as a source of infection and potentially a source of the fall. So at this point, are the the BP and heart rate, normal. Yes, BP 1 10/80. And I think heart rate we said was was uh yeah, within normal range, 72 normal 75. Yeah. Ok. So I think those are reassuring signs. Nonetheless, I think at this point, um if there's urine on the floor, that could suggest some level of um incontinence or it could suggest, yeah, it could just, that's why I want to put a catheter in. Um I would and I guess it could be that they're very unwell and that's the reason for the fall. So I'd want to, I think it's reasonable to send off some tests as per the sepsis, sort of standard sepsis bundle. So I'd want to take a VBG to get a um lactate reading. I don't want the catheter um just to help uh get a better sense of the fluid status and fluid input output. Um their BP is fine. So I don't think I would need to do a bolus. Um I think it's, I'm assuming it's a more elderly patient. So if the observations are stable, I don't think it's wise to necessarily give a big fluid bolus. Um I don't think we need oxygen at this point either. But I'd also want to take blood cultures. And um I'd also, I think I'd want to consider starting some empirical antibiotic therapy at this point. Um I think it's reasonable actually to do a quick, actually. Sorry. What was the age of the patient patient? 77 77. Ok. I think urine outputs a urine dip is not reasonable. Then uh I want to send a urine MS U and I think it's reasonable to start some empirical antibiotic therapy. What's their temperature? Is it normal? So you did ask for the temperature. So temperature is 38.4 degrees. Yeah. So I think reasonable to start some um empirical antibiotics. I'd want to go according to trust guidelines. But off the top of my head, I think it's reasonable to start with Carla IV at this point. So I want and also I'd want of course, um two large cannula in case the patient does deteriorate and needs fluid resuscitation, but also to give the antibiotics. Could you tell me which blood test you'd like to order for this patient? Sure. So I definitely want a full blood count to assess white cells. CRP as infection marks as well. Use need to assess kidney function. See if they're in A K I um as can happen in sepsis. I don't think LS TS are indicated at this moment in time. Also definitely want a set of blood cultures sent off as Well, um, she's a diabetic patient. So I think I'd want to do a finger prick glucose as well and a finger prick ketones just to check that there's not any concerns from that point of view. And if there were, then I'd want to start a sliding scale on this lady. Mhm. Great. So, uh, CBG six ketones 0.1. Uh, you do a venous gas electrolytes all within normal range as is HB lactate is 3.4. Ok. Um So it's a bit higher than I want. So I think um hm I think I've started the anti empirical therapy. I think at this moment in time with that lactate, I'd quite like to get my senior involved. So I just inform there's Unbel Unwell patient on the ward. Um I'd update them on everything that I've done. I'd ask if there's anything else they'd like me to do. Um I think it's reasonable to check for other sources of infection as well. Um Given the likely cause likely diagnosis of sepsis. So I continue with my A te um I'd want to um assess their G CS. We've got the glucose already. Um I'd want to check for any because they've had a fall and I am treating potential sepsis. I would not want to neglect the actual fall itself. So I want to assess for whether a CT head is indicated, for example, basal skull fracture, uh battle sign any bruising around the eyes and I'd also want to do a full, I'd like to expose the patient appropriately. Look for any other sources of infection, such as any drains or lines, um, any cellulitis. And I'd also, and, and, and act accordingly. But I think at this point I'd also, and also I want to consider a chest x-ray well done. And just finally, so you've alluded to the possibility of there being trauma and you've checked the medical, uh, the records and identified they're not on any anticoagulant medications. Um, the nurse says that it was a controlled fall. So the HGA was able to help the patient down, there was, uh, no trauma sustained to the head or body. Um, given that there, uh, was, er, also incontinence during this episode, er, and you weren't witness to the fall. Is there any specific questions in addition that you'd like to ask to those who did witness the fall? Sure. So with a raised lactate and a absolute incontinence, I guess, because it is witness, I'd like to say a full class history from anyone who was there about focusing on the specific aspects of before, during and after. Key questions I think are during, um, whether there, so it was incontinence with the, any tongue biting, any sort of jerking or seizure like movements after I'd like to check for assess for postnatal confusion to, again, assess if this was a seizure. And I'd like to see if there are any events preceding the fall, which could indicate a cause. So for example, any trauma, whether it was um postural, whether the patient reports any dizziness, confusion preceding, whether there's a prodrome um as well. So those are the key, so key questions I'd like to ask. Great. Thank you, Johnny. We can end the. Mhm. I think, ok, I thought Johnny did really well there, I was trying to interrupt him a lot and um sort of throw him off with things, but he reacted. Well, it's important to always keep the structure of the A two E in your head. Sometimes you can start off with it but then get derailed with questions. So um always make sure that that sort of your safe space can be the A two E if you ever get lost. It's your lighthouse in the storm. So a few questions when mentioned diabetic between A versus B, you allowed to ask the nur to take blood glucose and ketones as you carry on the A two E assessment, I would say the answer is yes, absolutely. Um Provided your, obviously the reason for the A two E is that it's ordered, the systems are ordered. Um in terms of what, which deficiencies will essentially kill the patient first. So for you to jump straight to dre and do glucose and miss see would be inappropriate. But to ask the nurse to take um glucose while you, while you still carry on with B would be absolutely fine. Of course, hypoglycemia is one of those slightly ids sorry, idiosyncratic ones where sort of D slash e will contribute to a because hypoglycemia ultimately could stop them breathing. So, yeah, I think that's fine. At what point should you show that you call for help, escalate early? You mention lack of. Um Yeah, I mean, to be honest with regards to calling for help, um it an easy way, I would say an easy get out for that sort of a way of like just a kind of a way of always making sure you've escalated appropriately without looking as though you can't handle the situation is right at the beginning. Say, given that there's an unwell patient, if my registrars is around, I'd like to inform them that I'm going to go and assess the patient that way they're aware of the, the patient and should I need to escalate further? They already are pre warned. I think that's a good way of basically covering yourself when it comes to escalation. Um I mean, I think any, once you assess if there's any airway problem obviously per call because you need anesthetist, um I, I don't want to be too black and white when it comes to escalation cos it, I think that's something that has to be a bit organic and it's very specific to the scenario. But um I think escalating early is always better than escalating too late. Er, just as it would be in real life. Er, is this recorded? Yes. Are you supposed to ask questions from the interviewer to direct you or are you supposed to try and cover every now again? I, I mean, I, I don't know, it will depend on the interviewer. I try to take different approaches to interviewing each person, er, try and suss out the interviewer as you go because obviously in addition to them judging you on your clinical prowess, unfortunately, because we are all human, there may be an element of, you know, how much they like you. So ju just try to kind of gauge whether or not they want to give you all the information, whether they want you to ask questions, you ask one question and they grimace, maybe take that as an indication that you shouldn't ask anymore. Er, but I think it's good to ask interview questions because it shows that you're sort of thinking actively and it also allows you to guide the direction of the interview a bit more. Sometimes being reactionary in interviews can just end, end you up sort of being backed into a corner. How would you address the nursery bedsores? Um, I forgot, did I mention something about bedsores? I, I can't remember if so then, yeah, it's good to mention that you'd obviously bedsores need to be deed, the nurses would do that and other doctors. But yeah, mention it to the nurse in charge. Any nursing issue. Always go to the nurse in charge. Never reprimand a nurse yourself. It's not your job or your responsibility. So generally speaking, any nursing issues direct to, to the nurse in charge. Um ok, let's move on to the next one. So this is Christy now for you following along on the thing. Um Proceed, continue. Yeah. All right, great. Thank you Christy. So now moving on to the clinical interview, have you read through the abstract? Yeah, I have. Yeah, great. So could you tell me as the on call surgical F one, how you'd approach this situation? So at the moment, I have quite a few priorities sort of um coming at me at the same time. So I've got an unwell patient um who is desaturating, which I'm quite who I'm quite worried and I've got her son who have some concerns about her care. Um And the third one is a police officer um who I'm not sure um whether he should be involved in the, in uh in the patients care, et cetera, but I will prioritize patient one because um if uh she's got clinical deterioration and patient safety should come first, I would ask the nurse to find out what the police officer would like to talk about. And um also thinking about patient confidentiality because depending on the type of wound that patient come in with, um I might not be able to um disclose um to a police officer. Um And if there's any clinically, uh anything that clinically worries, um, them about from the police officer, whether they can hand over to the nurse or if they can wait or if we can contact them later to talk about what they want to talk about. Um, and on my way to assess the 85 year old lady, I would notify my, um, registrar in A&E through bleep. If there's no reply, I might call the uh medical registrar. Um So just to escalate earlier and make them aware that um there's the patient because um in my mind, I'm thinking of a possible postoperative pulmonary embolism. Um or maybe it can just be an atelectasis a a hospital acquired pneumonia uh as well. So, um in my head, I would be thinking about what sort of management I might want to do on my way um to assess the patient. Um So, so sorry to interject. So you, you call your, your surgical registrar. Um She's in the theater at the moment and tells you that she'll be able to come and join you in about 20 to 30 minutes, ask you to first review the patient, she knows the patient well and recalls that they have COPD. So you go now to assess the patient. Ok. So I think um another differential uh that would add to my list is um probably an exacerbation of COPD as well. Um And so before I go to the patient, I would briefly read through the patient notes and drug chart and speak to the nurse about what happened. Um When did it sort of started uh in terms of the desaturation and a patient feeling unwell and I'll bring the nurse with me so that um she he or she can uh help me to assess and carry out management for the patient. So I'm sure when I walk to the bedside, the sun would be there as well. So, um I would explain to him that there's an, there's a medical emergency that I'm worried about. And um I would like to, I can speak to him after I have assessed his mom. And um especially because we're worried about, about her breathing. That could be something serious and ask him to step outside while um we assess the patient. Um So I'll uh do a quick to a to e uh do a quick uh history of presenting complaint with the patient if the patient is conscious, um to see to get a brief history of what happened. So when you arrive, so when you arrive at the patient, she looks visibly agitated, you explain to her some that the priorities to assess her medically, which he understands and steps aside. Um he, you then uh note that her airway is patent, she's able to speak to you, but she does seem to be breathing quickly. Ok. So, um as the airway is patent, um I will not um perform any airway maneuvers or put any airway adjust. So, um I will move on to assessing breathing. Um uh So saturation is low around 87. Uh I would assess for equal chest expansion listening to the chest and also across the chest. Um and I would give her oxygen um through the nasal cannula first and see whether her saturation improves. And I would do a, an A BG uh to assess her um arterial um oxygen saturation and I would order a chest x-ray urgently. And so you've uh you've performed your ABG bicarbonate level on the ABG is 32 the uh oxygen is six and the PH is 7.34. OK. So the patient is at the dot slightly acidotic. Um Is there a carbon dioxide level? Carbon dioxide is 77. So this a, so you've already escalated to your surgical registrar very appropriately. Um They're not able to attend at the moment. You've also identified that this patient has a raise bicarbonate type two respiratory failure and is a known smoker. You look at your S A TS probe which is currently showing a saturation of 96 having put the, I think you said nasal cannula onto the patient. So um with the history of COPD and uh type two respiratory failure and high bicarbonate, um I would be weary of um A CO2 retainer. So I would actually take off the nasal cannula because her um oxygen uh oxygen saturation should be 82 82 to 88%. Um 88 to 92% sorry, 88 to 92%. Um So I would actually take off her nasal cannula and then see how the saturation goes, but her saturation was 87%. So it's still slightly lower than how she that fine. So you can, I've quizzed you a lot there about uh about the breathing. So you can um ask the nurse to maintain SAS 88 to 92 and they'll manage that for you. So then moving on, you've ordered the chest x-ray the portable, but that won't happen quite yet. Moving on to circulatory assessment. Yeah. So um I'm looking for any signs of cyanosis um where whether there's a raised JVP um and pulse, whether it's uh regular or irregular, um looking for heart rate, BP, re refill temperature and also um doing an ECG as well. Ok. So observations all within normal range expect for respiratory rate, which is 21. The patients also complaining of sudden onset chest pain, which is worse on deep breathing. Um You've listened to the chest and not heard anything significant. Uh an EC an ECG that was helpfully performed while you were attending the patient shows um sinus tachycardia. OK. So with the um history and the presentation of uh ple chest pain, I would be um uh the top differential that I would uh want to uh rule out is a pe. So uh apart from ordering chest x-ray, um I would also um order AC TP A and start a treatment dose, low molecular wep uh weight heparin, for example, in Oxin. Um while we're waiting for the CTP A and then if the CTP A is clear, then um I will stop the low molecular weight heparin. So, absolutely, you're right to, to identify that pe is one of the top differentials here. Are there any potential contraindications that that might exist to, to an anticoagulant? Uh with regards to this patient specifically? Yeah. So, um because she is a postoperative. So, um I would be looking for any signs of bleeding or any uh from the wound site um as well. Um So I would go and expose the patient and look for any sort of clear signs of bleeding uh through the wound as well. Um Yeah. And of course, you would have performed a, a thorough examination including an abdominal uh palpation to identify any um risk of uh intra-abdominal hemorrhage or, or anastomotic leak. And going back to A I would assess her disability, blood glucose, gcs and pupils. Yeah, absolutely. So, your, your surgical registrar has now arrived, they think that uh this patient could also benefit from a medical review. So you call the medical registrar additionally. Um while they're, they, they're on their way, are there any final blood tests that you could send off for this patient? So, um I would send off a full blood count, um your knees, um nerve function test CRP and uh d-dimer. Although d-dimer will be raised uh postoperatively, um it might show if it's a very, very high d-dimer, then maybe it will show AC TP. Um It will show that suggestive of a pe and uh yeah, absolutely. And coagulation could be of benefit to uh as you've said, uh this patient is quite complex. Um, so it's appropriate for you to await senior attendance prior to making any definitive management decisions. Um, going back now to the police officer asking about the traumatic injuries. You've already spoken a bit on this, er, if you could just outline for us, er, under loosely, under what circumstances, you might be obliged to divulge information to the police regardless of the patient's wishes. Um, so I think if it's a gunshot on knife wound, um, where the patient is assaulted, um, from those, um, uh, mechanism of injury because I think there's a risk to public safety if that's happening. Um, yeah. Ah, yes, absolutely in the interests of patient or public safety. So, thank you very much Christy. I think we can finish there. Thank you. Ok. Um, sorry, I paused with myself staring ominously into the camera there. Uh, Tansen is asked, do you need to memorize normal ranges for blood and ABG S my guess would be not. Um, I think it was probably a bit tough on um, Christy there giving her b er, blood gas results, verbally, I would assume that you wouldn't have to do that. You don't generally have to do that for, um, medical school finals. So I would guess that you don't need to memorize normal ranges, but, er, it can't hurt if you do know them and if there are no other questions, I will move on to the next recording. Yeah. So this is for those of you following on reading the vignettes. Ok. Hi. Welcome to your London SFP interview. Thank you for coming. Who's bleeping me? The nurse? So I in any situation where there is multiple uh being uh hb A one c less than 6% sorry nightmare. That's the sort of cut off that they uh have chosen Mill. Thank you. So have you read through the uh vignette? Uh Yeah, let me just bring it, scroll down to bring it up on my screen? Sure. Yeah. Yeah, I've had a chance to read through so we can start whenever? Great. So could you tell me how you would approach this situation as the F one on a night shift? Uh So I in any situation where uh there is multiple uh patients that I'm being asked to tend to, I would prioritize based on patient safety. And in this case, uh although I have limited information, the patient who's having chest pain or shortness of breath, uh that would make me uh more worried uh, than the patient who I've been asked to verify that for. Uh and that's why I prioritize that patient over the other patient who has unfortunately, and sadly passed away already. So prioritize the patient who's clinically unwell at the moment. Uh As I said, there's not much information in the vignette to ask the uh person who's believe me, the nurse to, uh, give me a bit more of a handover if they're able to a bit of a back story about the patient as well as uh taking a full set of observations uh trying to find the patients, no, in your chart. And because of the chest pain, perhaps uh getting someone to do a 12 ECG as well. Uh in the meantime, and I would go with the intention of uh performing an A T assessment of the patient. Mhm. Absolutely. So what would be going through your mind as you were walking to attend the patient? Say you're on a different floor and you, you have to take the stairs. So a patient who is admitted with chest pain and now has shortness of breath. Uh So things that would be going through my mind would be uh again, I'd like to know the cause and what, what was the initial thing that brought them with the chest pain? But things going through my mind that would be potential life-threatening emergencies would be uh another acute Co a acute Coronary syndrome uh or pulmonary edema. Uh and perhaps uh perhaps a pneumothorax as well. Those would be the things that I would definitely want to exclude and make sure that uh they're not there as they could be immediately lifethreatening. Ok. So you've asked for the um HC to do observations, you arrive at the patient's bedside, you see, he's visibly in discomfort and uh the ECG has been done, you see on the SATS probe, he's saturating at 93% on room air. How would you approach the situation at this point? Shall I say again, the patient is saturating 93%. Uh I'm assuming they're visibly uncomfortable but they are breathing and there are signs of life. So I just uh start on with my A T assessment. I'd get someone to uh get patient notes and drug chart especially and find information about any ce of care that this patient might have. I'd then introduce myself to the patient. If the patient was vocalizing and speaking back to me, I'd assume that they have a patent airway. Uh And I'd move to assessing their breathing. Uh Is there just to pause you, there, is there anything else you'd like to consider given an acute onset shortness of breath? Uh Anything in particular you'd want to be looking for uh during the airway assessment? Yeah. So I'd like to uh make sure that the trachea is central. Uh It's tension in the car. I'd like to listen for any added sign, uh, perhaps there is a foreign object or anything or secretions that might be occluding their airway that's causing the shortness of breath. Mm. And you, you know, there's no swelling, there's no erythema and, uh, the patient doesn't have any known allergies. So, uh, uh, a, as you were progressing to the, the breathing assessment, please continue there. Yeah. So, as you mentioned, those has been important if, uh, if we're thinking along the lines of anaphylaxis, which is another important thing and could be an airway emergency, but it seems like it's not the case. So in terms of breathing, uh I'd ask the C A for the respiratory rate and the oxygen saturation which we know already. Uh I then look at the work of breathing, check the tracheal position and do a respiratory exam to auscultate to make sure there is adequate air entry and equal breath signs. Mhm And um and following that, yeah, so the saturations are 93% in the room. Ma So I think at that point, uh there is no need for supplementary oxygen, but I would keep an eye on them. Uh just in case if they drop below, then we would consider high flow oxygen. Uh Again, if I picked up any respiratory pathology that was concerning to me, I'd consider doing an arterial blood gas and ordering a portable chest x-ray. Uh but if there was no concern that the Respi the pathology of of respiratory order. Uh I'd move to circulation assessment. The shortness of breath is quite a nonspecific symptom and could be uh due to other issues. Mhm. So you asked for the notes to be brought to you? I think uh when you arrived at the bedside. So uh the nurse in charge has helpful, informed you that the patient was admitted two days ago with unstable angina and they're currently awaiting a PCI which is not performed at this hospital. So you look at the ECG and you see changes that are consistent with acute ischemia. What would you like to do next? So, so uh this is a situation which is an emergency as it's uh likely that this patient now has uh either progressed or uh either has uh sort of ischemic changes that are suggested for ST elevation myocardial infarction. So, in this situation, I think uh it would be good, good opportunity to get help from my immediate senior or get help from the medical registrar uh with the prospect of speaking to the cardiology registrar in this hospital as well. Uh And then if I was uh based on the E CD changes and the chest pain pattern, uh if I was convinced that this is sort of a CS, then I would initiate the A CS treatment algorithm as well. Uh Those patients with 300 mg of aspirin, if they already weren't on it, I check the drug check to make sure uh how much they have taken before. If they were an unstable angina, I'd assume they would have gotten some aspirin earlier and they check again, check on which antiplatelet they were started on. Uh And then start speaking to cardiology, uh also consider GTN uh uh for sort of symptomatic relief for the patient. Uh I think in terms of oxygen, I'd keep an eye on the saturations uh and make sure they're within the normal ranges uh as well. And what would the normal range be for this patient? So I think you'd like to keep, I say, yeah, you'd like to keep them above 94%. So perhaps a bit of low entry oxygen would be good but not over oxygenating them. Mm And if you're aware of a significant smoking history within this patient's COPD diagnosis, how might uh the patients saturating 93% currently if they were to desaturate, how might you identify uh the most appropriate SAT target for them? Uh Yes, I think in a BG uh would be of great help. And then looking at the bicarbonate, whether they are chronic CO2 and P CO2 levels, looking at they're a chronic retainer. If they are, then uh dropping down to a scale 2 to 88 to 92% would be more appropriate. Uh But in the short term, if they're acutely desaturating hypoxia would be more dangerous, I'd be more, more concerned about that than hypercapnia. So if in doubt I'd start them on high flow oxygen and then there is always scope to then titrate them to the appropriate level and uh you've sensibly escalated uh the scenario to your seniors, uh say for some reason, they're delayed in attending the patient. What would be the particular features you'd be looking out for? That would make you even more concerned about this patient's acute deterioration that would potentially prompt a Perret or an arrest call. Yeah. So as you said, I think the threshold, if I was the only person on side, that's the one I think I'd have a low threshold. And if I saw any features of hemodynamic instability, uh such as hypertension or uh either tacho bradyarrhythmias uh or the patients becoming less responsive, they would be the triggers for me to, to put out PRS or an depending on the hospital I'm working in. Mm. And uh you've got an ECG that's shown uh is consistent with acute ischemic changes. Um You've compared that to their emission ecg and confirmed that uh the changes are new. Are there any blood tests that you would like to send at this point? Yeah. So I think the, I would like to set a full set of letters but so F PC is using a, I'd like to do a clotting as well because this patient is going for a PC later on er with the prospect of transfer to another center and send up a troponin and then send up repeat troponins as well to check whether they're a dynamic or adynamic. Uh So I would like to stay with the patient but if this was dragging on for longer and longer, then sending multiple troponins to compare uh how they're trending. Mm OK. And um you've, so you, you've managed the situation, the medical registrar has arrived, they've commenced an appropriate anti-platelet therapy and they're now discussing with the PC team at the relevant hospital. Er, you then are advised to attend any other urgent er, calls that you've had by the registrar. So you go to the patient for death confirmation, they're surrounded by their family who've now been waiting for two hours and are very displeased. Um You can see that uh the patient's daughter is in tears. How would you approach that situation? Yeah. So I think first of all, I would, you know, acknowledge the fact that this is definitely very upsetting for the family and I apologize for the delay uh trying to, to explain that it's caused by a medical emergency. Uh And then if the other emergency was being taken care of, I would then uh sort of try to uh to do the death certification. Uh I would explain to the family what I was planning to do and I would offer them either to stay or leave the room. Uh as they would like, I know that uh different relatives have sort of different preferences and the death certification process itself can be quite upsetting to the families, especially because they might not be sure why it's being performed in the way it's being performed by us. It's quite a particular process that requires you to do certain things for sort of periods of time longer than the public might expect to. Er, and I would explain to them, uh, if I knew the pa whether I knew the patients or not, uh, and whether I was just asked to confirm their deaf or whether I knew them in their last illness. Uh I would then offer my condolences and uh I would make, make sure that it's appropriately documented that ification and then that the family has been, that the bereavement services has been given appropriate information to contact the family. I'm assuming this is eight of hours. So that's perhaps gonna happen in our, uh and I perhaps use, uh ask the nurse in charge or uh whoever the nursing person on the ward this as well to, to make sure that the family uh has everything they need in the meantime and, and has the appropriate information. Thank you. That's a very comprehensive answer. And uh we can end there. Thanks very much, Vicar. Thank you. Hi. So just one question, about 2025 entry uh short listing. I would advise you to just check the, the guidance. Yeah, exactly. Maria's posted it. So just check the, uh the guidance and that's from 2023. So when you come to apply, check the current guidance, they update it every year. It's always changing. Is anything un bear in mind, it's written by one person that can make mistakes. So if there's ever any, uh, confusion or lack of clarity, always email them and they will respond, er, reasonably promptly. So finally, Sarah, just, er, to introduce this one, I think her vignette said something about, er, we wrote, er, dark stool or something about the blood. I forget now, but she essentially had it a bit tricky because I think we said Melina um, in her vignette but then changed it. So if, if, if you notice a bit of a hiccup when it comes to her diagnosing upper versus lower G I bleed, it wasn't her fault, it was our fault for the Vignette. I'll play it now f one on the night shift. Um, sure. So the first thing I would do is take into consideration both the patients who I've been handed over. So the first patient is someone with an episode of Melena. Um, and the second patient is someone who is agitated and confused. My first step would be to prioritize these patients determine how, which one should I see first. Now, based on what I've been given from this vignette, I would definitely go and see the first patient um, as a priority. Um, however, I would call the nurses back for the first patient. I would ask the nurse in the interim for the time it takes me to get there if that nurse could potentially do an ECG for me, do a set of observations for me. Um and also get the patient notes um out so I can read them um on getting to the scene for the second patient. However, I wouldn't want to leave them just like that without a safety net. So I would tell the nurse to um take into account the the stepdown measures that we would take for someone with delirium. Um because she's agitated and confused, I would tell the nurse to try and reorientate her, um remind her where she is um ensure that there's good lighting um and try and calm the patient down. Um I would also advise uh also safety net for the nurse and advise the nurse if the patient starts getting violence towards healthcare staff towards other patients to get security involved. Um And then I would go and see the first patient. Um So on arriving uh to the scene for the first patient, um I would have a quick look at the notes, I'm particularly just looking at, is there any relevant past medical history standing right there? And I would also look at if the patient has any allergies to anything. Um If I'm going to pre prescribing anything throughout my assessment of this patient, um I would also check because this patient is having um a bleed is their blood uh group status already known. Um And if not, I would just start my A TE assessment straight away anyways. Um So I would approach this patient using an uh an assessment, using an A TE method. So I would start by assessing the airway. Um I would check if it's patent if the patient is talking to me, um then I would move on to breathing. Does this patient have increased work of breathing? Um Is there anything on auscultation of the respiratory system um that I can hear? Um And if needed, if I was suspecting any respiratory pathology, which from the vignette, I don't necessarily um I might uh order a chest x-ray. I would also want to know their respiratory rates um if we have that and their oxygen saturations if we have that. Um So I the respiratory rate is 18 oxygen saturation, 96 on room air. Ok. So they're saturating fine respiratory rate is maybe a little bit on the high end, but that might be because they are unwell and I'm aware that their BP is, is low. Um So I would move on to uh circulation or c from there. Um So I would begin by auscultating um uh for the heart listening to the heart. Sorry. Um I would feel the radial pulse um bilaterally. Um And I will also check the capillary refill time if we have that. So, capillary refill is delayed. Uh the limbs peripherally feel cool and uh you repeat the BP in both arms and it's around 90/50 as the nurse reported to you over the phone. Ok. And do we have the patient's heart rate as well? The heart rate is 120? Ok. Um So they tell me that the patient is hemodynamically unstable. Um So what I would do moving on from there would be to insert two large bo IV Cannulas um in both antecubital fossa um in order to take blood first. So I would want to send off a full blood count. Um Urea and electrolytes, especially looking at urea serum. Um liver function tests c reactive protein and clotting. Um And I would also want to send off a group and save um for crossmatching. Um because this patient is also hemodynamically unstable. I would at this point also put out a major hemorrhage call. Um And I would start by administering um a 500 mL bolus of 0.9% saline. Um in order to hopefully get the BP to respond uh be in the time it takes to get blood products over. Mm So, could you tell me about uh you've mentioned appropriately putting out a major hemorrhage call? Could you tell me about what that means and um the benefit of doing that in this situation? Yeah. So for me, what that, what putting out a major hemorrhage uh call means um is to be able to get a group and save and cross match in to ensure that any blood this patient receives. Um that is not o negative blood um will be safe for them. It also means that the lab will be aware that the patient needs a transfusion and that they can get the blood ready in order for it to be sent to the ward. Um and it would also mean that the appropriate teams would be aware and that I would also receive senior help as this patient is acutely unwell. Mm Great. So it at different hospitals or trusts the protocol may be different. You clearly see the need to escalate to an an appropriate senior. So which uh which registrar would you want to be speaking with specifically in, in this, in this case? Sure. So because this is I'm suspecting a lower G I bleed. Um And so I would probably escalate this to a surgical registrar. Uh Could you tell me why you're suspecting a lower G I bleed in this patient? So this patient has Melena um which uh sorry, no, I'm suspecting an upper G I bleed, apologies. Um So this patient has uh Melena which is sticky, um tarry stool, usually sorry from an upper G I bleed. Um because the blood has essentially been uh digested and mixed in with the stool if they were frankly bleeding. Um from the rectum, I would be suspecting um a lower G I bleeded and given the the, that's fine. Thank you. So, on, on assessment, actually, let's say that when you look at this patient, you can see a fresh red Frank blood uh between the legs as well as some dark, foul smelling melena. So it's difficult to discern. Um Did you mention performing an ECG, given that the heart rate was high? So you see that that's sinus tachycardia. Uh But as you've correctly identified, the patient is hemodynamically unstable. So you started fluid resuscitation, put out the major hemorrhage call, what investigations do you think this patient might be requiring subsequently? Um So I definitely want so in the blood that I'd have put out, um, a full blood count to check the hemoglobin. Um, if this was an acute bleed, I wouldn't necessarily expect that to have dropped all of a sudden, but it's always important to have a baseline as well. Um The other specific thing I would be looking for is urea serum. Um, because that will tell us, um, whether or not this actually is an upper G I bleed. Um, if the urea is high. Um, and I would also be looking at clotting, um, mm, if there was anything that needs to be. And, uh, when, when speaking with the nurse, she tells you that the patient's lost approximately 400 mils of blood in the last 20 minutes. Um, you, you get while you're waiting for the major hemorrhage team to arrive, you, uh, take a venous blood gas which tells you that the hemoglobin currently is 105. Do you find that result to be reassuring at all? And could you tell me why the reason for your answer? Yeah. So for me, that's a reassuring, um, that's a reassuring level. If it's, uh, if it's 100 and five, that's not ideal and it is on the low side. However, the criteria for blood transfusion, at least in the chest that I've been exposed to is if they have a cardiac history, if the hemoglobin is below 80 that's a criteria for transfusion. And for everyone else, if the hemoglobin is less than 70 that's the criteria for transfusion. So, for me having hemoglobin of 100 at this point is reassuring. Ok. So given that it's an acute bleed within the last 30 minutes, uh the hemoglobin may not have dropped accordingly at this point. So it's you appropriately were guided initially by the hemodynamic states of the patient. And er you correctly uh were very concerned about the acute bleed and, and you put out all of the appropriate calls. Um So, uh what this is, um is there any specific information you'd like to gather? Uh once the team has arrived to try and discern what could be the cause of this bleed. So any risk questions you'd like to ask the patient things you'd like to look at past medical history uh, medications wise as well to, to guide how the type of bleed this could be and how you might therefore treat it. Um, sorry, can you repeat the question? You froze halfway through? Sorry. So, uh, firstly looking at medications, is there anything that you'd like to, to check, uh, that they've, whether they've had any certain medications, whether you'd like to hold them or change them? Um, yeah, definitely. So, I'd want to see, are there on, are they on any blood thinning medications, particularly any low molecular weight heparin, which they might be if they've been an inpatient, um, uh, any other blood thinners, any, do a, um, any, uh, anything like aspirin. So I'd want to, with withhold those medications if it was something like Warfarin might consider giving them vitamin K in order to reverse those effects. Um, yeah, and if you found that the patient had an excessive alcohol consumption in their history, how might that guide your diagnostic and investigative actions? Ok. So in terms of further investigations for someone with a significant alcohol history for an upper G I bleed, I'd be concerned of, um, variceal bleed. Um, so they would need to have a, uh, an OGD, I believe the need for an outpatient or inpatient O TT is calculated by the Blatchford score. Um, so I would want to calculate the Blatchford score, um, and determine how ill they are. And do they need one as an inpatient? Um, I would, so they would need an OTD in order to confirm the, the source of the bleed. Um And obviously, liaise with gastroenterology and surgical specialists. Um That's great. Er, are there any other scores that you can think of in relation to? Er, so Blatch, could you tell us what Latchford is, the output of Latchford? Sort of what the risk is actually communicating to us and, er, whether there are any other scores that you might use. Um Yeah, so there's the rock or score as well. Um Yeah, so the Gl Glasgow blas score, sorry, is whether or not an individual needs um a particular medical intervention, do they need a blood transfusion or endoscopy? Um sorry, the roca score is what's done before endoscopy. Um and it determines essentially the severity of G I bleeding. So whether or not they need uh it as an inpatient or if they can have it as outpatient, those are the two scores that I'm familiar with. Yeah, absolutely. So I, I believe Latchford is the requirement for intervention, as you say in rock all guides the er mortality risk, but you're aware that it's important to, to consider both. Er, thank you very much. I think we can finish there. Ok. Ok. That's all of the interviews. I thought that everyone did really well and we appreciate their input very much. Thank you Maria for answering the questions as we went along. So rabi asked about er, instances we do met calls per arrest calls. Again, it kind of depends. I wouldn't want to give sort of definitive rules on this, particularly Perret and arrests. Not all centers even have a pers call. Er, sometimes you just put in an arrest call. Um, if patient is Perret, er, again, it's really more about clinical concern rather than hard and fast um, thresholds, except for, as I say, sometimes news of seven can merit to me call. Obviously, if someone's arrested, they would need an arrest call. But it's probably, I would advise you asking um an, a medical consultant or a, a medical registrar and they'll probably be able to give you a better answer than I can. Um Yeah, so any o I can't see any other questions, Maria, do you, do you have anything to add? Anything you can think of? I haven't said I'm sure there's loads. No, no, no, you, you've heard everything. So on the feedback, you have a lot of questions specifically about the academic station and approaching the academic scenarios. So that's what, that's what I will be covering tomorrow. Um In the tutorial, it will be the same time around seven pm on Medal and you can sign up to get that link. So we'll be covering those questions and we do have a lot of other questions regarding composing yourself on the day of the interview. And all of that again, I've pre I've prepared those to cover tomorrow as well, kind of how to approach, preparing, how to approach, comment on nerves and things like that. Um Excellent Luc has just sent the link to sign up to the academic station tomorrow. Yeah, great. Yeah, make sure to tune in for Maria's um presentation tomorrow. I'm sure it will be extremely valuable. Thank you everyone for coming this evening. Uh I think we can wrap it up. I don't know how to end it. Lucas. Would you be able to end the?