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Okay, So, Hi, everyone. And welcome to the weapon out on surgical emergencies. We've got two great doctors, AB and Fatima who were going to be talking today s so I let her over to Fatima to give an introduction. Hey. Hi, guys. Eso if you've been tuning in for a weekly webinars, tonight's one is about surgical. Emergency is so massive. Topic, I hope, with a good job allergy and your fears about this, um, a full of, uh So, yeah, just if you haven't, uh, seeing us before. Albarus is a four doctor currently working northwest London. My name Strattera are also on a four doctor, also actually in the same area. Um, and today he's gonna be giving a talk. I'll just be kind of offering support, asking the questions. Um, based on your previous feedback, you said you wanted more kind of poles on, but we've tried to organize that behind the scenes in various ways. We're going to trial this way today, so if you've heard of coots, you know how it works. If you haven't, it's really, uh, really simple to use. So, uh, if you want to join in with that, you can So, uh, join on the website. Information is on the screen now, but in case you're just listening, so it's w w w dot coots k a hate double o T i d. Alternatively with the Kohut, Um, and there's a code on screen now what you need to enter to enter the game. So it's 9695760. Um, and if you log in, then you'll be able to take part in the questions on. Go throughout. We'll have a couple of questions scattered around on. I will let you know the results of those as we go along as well. Um, so I'll 100 bike over to Ah Gianvi? I think so. Just a quick shoutout class sponsors that, um, do you don't forget before starting your F one year to build out your MD you membership. If you've already have a student one. We don't forget that this will run out in summer, so it's essential that you have indemnity cover. I'll put some links if you have any questions for M D U. On just that. Everyone knows at the end of the session, just before the Q and A or just after have someone from the BMA will be joining on just giving a shot up to the health that they offer a swell, um on. Then we go to the give away slide. Sorry. I was looking into the names popping up or your coupon. Go ahead. Eso just quickly before abstracts. I'm sure you all very keen for that. We just want to give another shot out for our courses on mind a bleep dot com. So we've got to give a way to win. Ah, membership for our sweet and salty course. So don't forget to felt that out as well. On the link is on your screen now. Okay. I think that's everything for me. Czar passed over toe AB to get started. All right, guys, a low. Um Okay. Ah, right. So let's just pull on this. So we had a couple of people going. How many we have joining so far? Ah, so many. Ah ha guana over here. Basil's popped in. We got some emoji faces. Uh, EJD the DJ, uh, lidocaine to soothe your pain away. Gangrene. It's like you guys will talk about different things. I love it. Okay, so, um, hopefully jab. You can pop the code on to, ah, Facebook live stream so that people come up later. They can They can have a chat. The the reason we haven't put this in before is just because there's a delay between our zoom cool on the Facebook like stream of, like, 30 seconds. So it means I can't really assess how well I've been teaching you guys because I have to wait like a minute or two after the slide. Why? Can do is use this to assess what you guys were thinking beforehand. So on the mobile, it'll probably pop up just before I start talking about the fact we're on the next question, you have about 15 20 seconds to answer it. Don't take the two minutes. I'm just leaving that to give me time. Um, and then we'll go through, uh, the answers afterwards, Um, and this is more just to get you in the minds of were thinking about this. We're talking about this just so you start thinking about the right the neck top, we're going to be going on, too, in terms off the contents. So we're, uh we're yourself by talking about the scope of this thing because surgical emergencies is huge on D. I do know have the ability of going through all of it in an hour and actually giving you anything meaningful out of it. Ah, we'll be talking about some 80 stuff. Um, the airway emergencies, which is there's two that I can think of the surgical the, um that we're going to tell you about, um, head injuries, which is something that lot of one that on the medical wards deal with. Ah, abdominal stuff? No, just, uh no, just general surgeon. But the vascular, your old stuff is well on. Just generally the stuff that on F one on the ward that's medical, uh, might see in their patients. So right, let me start up. We have so many people. Okay, let's start this thing. So, uh, question number one is which one of the four conditions that they're gonna poke on your screen are, uh, conclude a patient first? Um, uh, patient. The quickest. And while that was going on, um, let's talk about the scope of this thing. Um, So what? I want to start by saying that this is mainly for the medical doctors that will be on the medical war. This isn't for the surgeons. Doesn't mean they they can switch off. But I'm not going through the surgery aspect off these things. I'm going to be trying to equip the medical doctors to know when they need to contact the surgical team. Which surgical team to contact on what to do before contacting them? Uh, it's gonna discuss terms they're going to be using in their referrals. I might also tell you about the initial management stuff to do with these conditions just so you can keep patients stable whilst you wait a specialist review. Um, also F ones, I think are more likely to do ward cover than Clarkin. And generally, when they do clark ing, they shouldn't be given the complex cases this week in the box. And when they just need someone to do the clerking azelas that in my experience, the register generally post take those one of the ones, um, patient's the fastest. They just and they'll pick up any issues. Um, uh, or pick up the fact that needs to be a have a surgical referral in there as well. So I'm not gonna discussed much on the diagnosing of it. Um, I'm gonna be going in the mindset that you're, um you're having a medical patient with medical problem. And they have this surgery cold. You pop up during the middle of the admission. I'm not going to go into trauma because that's his own thing. And that's here. And Ah, and you shouldn't be attempting to beat your patients. So I'm not going to trauma. I'm not gonna go into kids because peed in his own specialty at the whole load. More surgical emergencies, uh, that are on. Most of my patients need senior support, so you'll be calling your Boston for them. So I'm not gonna get that either. Finally, nothing about burns patients are mildly fallible. But if you test this, then is generally frowned upon. So we're not going to burn either. Um Okay. So, uh, we're gonna, uh, what's the time on this one? And it's done. So the responses are so these are scoreboards from the moment I'm gonna keep opening. And now I like Ah, yeah. Being has an Eggo currently leading the leading to think. Yet, by the way, the correct response was, um, the airway emergencies So 80 Um, I want to start off by saying that in most cases you'll have time to do an 80 When you're suspensions. It's patients are a lot better at keeping themselves stable than than I gave him credit for when I left Met life. It's an emergency. They're gonna get unwell really quickly on gonna die really quickly. You have time to do a second on the 80. Also help buy you more time, because you'll it goes in the order of things they're gonna kill the patient on. You'll start doing things to address it to protect them. Okay, you'll learn the Unlike in the movies, people don't run for medical emergency calls. Cardiac, cardiac arrest. Maybe they do, but medical emergency cools. People don't run from them, so you'll have a little bit of time after you put the cool out to do something on it. Probably better than just twiddling your thumbs. If you do start the 80 and start trying to stabilize the patient, you should be familiar with the 80 assessment. It's on the page there airways breathing, circulation, disability, then everything else. Not going to go into that right now is ah whole host of resources out there that can help with the, uh, paramedics use it as well. Um, it's part of ah, of 80 less. What have you So so I'm going to go through that one. You can Ah, you can go through it on your own time. I'll just point out with something to pay attention to. On your first job was an F one is to be safe. Your second job is to learn how to be a good doctor when I take the third one is to help other members of the team and someone that's able to run and 80 before attempting to refer to their own senior is miles ahead of someone who just cools off the right thing. I'm concerned. I don't know what's going on. I haven't quantified anything. The one that's already done something assessed something, maybe had some sort of management plan going already, they're going to have more used to their seniors. So question, too, Um, after securing the airway, what's the next party assess that? Let me see if I can start question up here. Fact, um, are you around? I am yet fans so often security head head in your patient right off to securing the airway. What's the next part of the assessment when a patient fools on the ward and hit their head? I know you're trying to touch me out. Oh, yeah, You may have seen this before, but don't. But we're going so the options are breathing. Slash rest C spine, assess the skull or do a full cranial nerve acts on what you think. In fact, on what you think. And I mean, it's a a B c the you so off the airway. Obviously, uh, they're in stencil breathing, but is head injuries with different All right, guys. So spoilers. We were hoping that that it would get them wrong. So the people are getting the wrong but fasting with chicken. Well, these people are not going to trust me. I'm just doing next week's webinar, so Oh, yeah, that's true. They need the chief. She's a good doctor. I probably I probably Okay, let's go to the Let's Go to the the next part that the airway emergencies before we get the head injuries. So there are two. Thank you for calling you again. Um So there are two scenarios that I think are probably there are a issues and these are the ones where you probably need to get something going before the medical would arrive because they're very time dependent. They're also both in ent. So, uh, it's very specific toe that specialty or or if you're covering into your chart of Genser Ah, two things so you can see on the image there, there's Ah, there's, ah, surgical scar from, ah, thyroid surgery. So post thyroid surgery. If they have a bleed, they have. They have something called an expanding hematoma, which means that basically just bleeding out into the space in the front there neck and that's going to slowly start compressing on their airway. You might. So you'll notice Strider. They'll be quite distressed. Late stage hypoc sick blue, blue in the lips And what have you when you start seeing, um, signs of respiratory distress? That's what you need to relieve it. So you should have been calling the red when you noted it, because the regimens to get him because the way to fix this is surgically exploring the wound and, uh, stopping the bleeding. But when you noticed the airway compromise itself you cut the suitors, open that area up to allow the blood to come out. Put a loose dressing over it. Just Ah, try and absorb some of the blood. Don't put much pressure on it because you don't want to choke them yourself. Um, and you wait a Reg to come along so you can so they could be assessed and taking the theaters and matter of urgency. It's very rare for that to happen, though I haven't had it drawn my during my six or so five or so months experienced in the empty, Um, the other thing even less like that happened is a torrential bleed post tonsillectomy. That's a primary bleed. So they've had a tonsillectomy, and they have a massive bleed. Um, you get sitting forward, you getting spitting out the blood from their mouth, they can kill, still try and keep breathing through their nose. Um, and you call the rep in this one, you try, and you can do the 80 is Well, uh, and just keep in mind for see if they lose a lot of blood You want to try and replace it with, uh ah, we some blood is some fluid. Teo, stabilize there. Observations while you wait for them to be taking back to centers for small bleeds register. Probably call tries on the ward. Not to worry about those. The two things. No. I think you may not have time to fill 80 on, but we need this. All right, so head injury, right. Well, we got for the results. Um, so 51 said breathing arrest 48 said, Ah, see saline. So I think 51 51 of you guys Ah, fell for for Fatima's trick there. Um, with truma, uh, c spine and goes just before, um, just before breathing. Because if you're moving the neck around and you pull on it accidentally and use ever there seven their their spine, then they start. Ah, well, it's a problem that could stop breathing or bring the direct their process. And what have you So you So the C spine is the next thing that you protect. Ofter You protect the airway, and then you go into breathing, uh, on the current, uh, A and A and E. So the emergency guys are doing well right now. Um, let's go into head injuries. The one drug and discussing his head injuries because it could happen. Pools could happen on the ward with slippery socks. They have their attacks to catheterize that catches something there. Old peripheral vascular disease. Come figure out whether you sometimes an F one specifically overnight you're gonna be asked to assess, um and go from there. My partner talks really going to go on talk about what happens if there's a bleed or if there's decreased GCS. If you're mostly schools, have their own performer. Uh, and if you're performer in the ah, an examination indicates their fine. There may also be some administer struck administrative stuff you need to do like risk assessments for why they found how we're gonna address that in future. But that changed mean trust I'm not gonna get so you could see a patient overnight. They form well, you what you do if they're on the ground, Um, and they're able to get up where they're getting up themselves. Get them on the bed so you can assess them if they can't get on the bed or they haven't tried to move the lives and they're still in the ground, then you need to clear their C spine before you get them on the bed. The way I use it is something called the Canada C Spine guidelines. Um, it's on MD calculate do Canada C spine. It'll be there. But one of the first things that that stops it is if your patients aged over 65 which is gonna be a lot of your patients, um, your own performance may have different restaurant fires that say does expect you need a CT scan of their C spine or no, if you can clear the C spine good. Makes life easier. If you can't, you need to keep the c spine immobilized. The way that I was taught this when I was in a any is that the head of the patients here? The body's further up, and I'm the head of the patient. I take my hands and I grabbed their traps and I used my forearms to, ah to squeeze their head between my forms, and that keeps him stable. And I stay like that. If you could get one of the nurses to do that, that's really good cause then it frees your hands up, Um, and then you need to get some blocks here. Blair, which I orange blocker you put on the side of the neck and you tape it there so they can't move their head around. And while you wait for the rest of stuff, I'm not gonna go have to do the C spine checks because it takes another five minutes on D. But you can look up online and terms of YouTube stuff out how to do that. Let's say the C spine is clear and you're assessing them in the bed. Next thing you're doing is looking for signs of basil skull fracture were depressed, call fracture, assessing the GCS and comparing to their baseline. So if their GI says 14, but they're always basically they're confused there, always a little bit confused, has no off their baseline is not too bad. Assess for loss of consciousness and seizures and see if there's any other indications for a CT. Had Nice have put out a really good flow chart that indicates, uh, who gets a CT head and also within what timeframe within one hour or within eight hours, and it's based on stuff like are they on anticoagulants and stuff like that? So go and have a look at that. That'll help you. Um, if when you get there, the patient's unstable. So Jesus is less than eight. Where there's really abnormal breathing. I would class as an emergency. So you to put in emergency call out to make sure, and this just gets there or night to go. I guess they're sometimes met. Calls in hospitals. Don't have anesthetist or someone that can intimate, uh, come along to the call to make sure you put out cool that gets your nieces. They're see, Protect that airway. You probably also, when your boss is there a swell, because once they get the airway and if they've intubated, then they'll they might need to go in ventilation, Which means need to have a have a discussion of how far we're gonna go. Those patients are they Do they go I to you or they award basically care. Um, after you get got time to put that call out, you're gonna wanna do Ah, put some lotion on them with a mask on, put your and do it. Your trust. You can't do the head tilt just because you're trying to take the airway. Um So what you do is you put your, um, the pads of your hands on to the patient's cheeks like so. And then you wrap your fingers around their head like the face hunger from a li in until it goes behind the Ramus of the of the man and you just pull it forward. It's painful. So if they're JCs is more than eight, they may wake up and they may. They may contact you around, but it was last night. Then you're helping keep their tongue out of their pharynx. Um, if there's no indication for CT had good Father is a former will come in, you're done. If there's a CT had indicated in the patient's stable, uh, where there's concern regarding any sort of brain bleed, inform your senior get a CT had done and then refer to neurosurgeon. Okay, so the three outcomes patients really unstable. Put on that cool because you could need ah, you need someone to secure the airway. You're gonna need the bosses to come in to make a plan. Patient's stable and they don't need a CT head. Fill out the paperwork Done. Patient's stable, but they do need to speed ahead, Get it done. If there's a bleed, refer to certain, um, next one goes parents. Um have we? Yeah, we have already done for. The next one is gonna be late once we're going to go into questions just yet. So, Peritus, um, now, this is a word that's running around a lot, which is kinda use interchangeably for pain in the tummy. It's know that a general surgeon doesn't doesn't like it being used for that has specific meaning. Um, and the parasitism congee, uh, localized or generalized, and that really affect the layer of the parent. Any, um, that's affected. Um, and you're looking for three things guarding, um rebound, tenderness and board like rigidity for it to be parents. So with the garden, it could be localized or generalized. Um, specifically, it'll be if there's a specific organ that's being hurt, that'll be where the garden is going to be around. If it's gotten extensive, nothing's going through both layers of paraphrenia. Um, it's involuntary, which means that if you're distracting them talking about their day, we'll have you and you're just being very gentle and going in there and they're not tensing Then that means that they were a voluntary guarding beforehand. It's not the same thing Rebound tends. So classical way of doing it. Press in hold of it to pull out, see if it hurts more poking through it. Very mean. My bosses say You know what? Dual percussive tenderness is pretty sensitive for that as well. Just put your hand over there and just do a little bit of protesting over that area. They find that painful. Then that's, Ah, you can use interchangeably with rebound tenders is less mean to, um, board like rigidity. So a lot of the time Ah, when I was in, ah Genser genetic got referrals from the e. D or won't have you. There was the patient would be said to have imperative in a great deal abdominal pain, and I can see them from where they're referring and they're writhing around. If they're writhing around. It's probably not parroting is because you're trying to protect your viscera by not moving. You become stock. Still like a board. If they're rising, is probably your tear it call it, um, or something or something retroperitoneal or something like or it's not true, parent, Um, these aren't build on end. Or but that's the general. Just things. If you see a patient and they're stock still not moving, they have difficulty getting up in the bed and stuff like that. That's something that surgeons find concerning why this even important. Because when you use this word parroting is, um, to a surgeon, it indicates there's some sort of emergency that they need to care about. Perforations gonna have parents. This general, uh, complex issue is gonna have parents. Uh, so when you in your for a ways, a parenting is, um we treat it is it's important there's this image. Basically, you might have to be difficult. Seen it on ah, on your phones. But if you just search ah, accordance of the abdomen differential diagnosis. It says that if you split the abdomen to nine different parts, um, the organ underneath it and just just to, uh next to those sections as well is the probably gonna be the cause of the pain. So if it's the right upper quadrant gold bladder biliary system, right. Lower quadrant pendants left lower quadrant. Diverticulitis will come through in a second thorax. So at this point, we're not basically is going down the body. Thor x ah. Lot of stuff to go wrong with your ex and it's pretty catastrophic. But generally people present with, um rather than they have them happened during their admission. Um, so not going to be too much with stuff like breast breast happens. And what have you all go that when I talk about breast, the only thing I want to say it surgically about I'm going to Ah, no matter. No more authorities and stuff like that. Um, the only one I'm gonna go into is the ah is an aortic dissection, which is about which is a vascular issue because it's good at mimicking an M I. The difference is it's typically a tearing pain, but it can still be short progressing. So initially it's retrosternal and then it progresses to the back is the is the terror continues down there a water. As the tear happens, you can compromise the vessels that come off it so it could compromise the blood supply for the arms where they will be paraseizures. What have you It's that that's pretty late. Late. Sign it when that happens. Um, difference from an m. I it's immediately works on M I. That's amore worsening pain. But with both initially doing the city because and aortic dissection been still involved, the coronary arteries. And that could be that could I think you have an MRI at the same time. The reason that's important is because with them I you and you think about thrombolysis with a dietician, you don't you don't want to do that. So if you're thinking, is this an area dissection going instead? Have a chat with your boss's because the management stuff is gonna be stuff like medically lowering their BP. Um, which is not something that you normally do. And it's something that needs monitoring without you. And it's to you, Um, and they'll need to get a CT scan there, which I don't normally get if it's part of an M I pathway. So if you're thinking is that have a chat to your boss? Is, um, when you get a chance? Uh, the sooner the better. Really, uh, soon as you do your 80 like I said, Breast, I'll talk to about there, okay, and three fingers on Brother's Fatima going to call call you back in. If That's okay. Well, hello. That's so this time we'll be talking about her in years. What I want you guys to think about is what is going on. Let's get the question. What is the most common hernia for a woman to get? Fatima Now, I know you are mainly trauma north of acne. Like when we're working there. But you did some time in Genser church. Which, which one do you think is the right one? Questions I don't actually have. The question of the options are femoral big l e in inguinal and lighter. What do you got? And what was that? Also like her? L a t T R e is meckel's diverticulum. Okay. Okay, um I know you're trying to trick people again, because what do you want me to really answer? You make over. I mean, let let's let's have you roll. Your, uh the thing is, because you always get taught medical school, don't you that, like, femoral hernias are more common in females. Yeah, but that's not the most common hernia they get. Okay, Okay. So what if I don't? I don't actually, you don't know? I mean, I wrote this question for this very, very, very sweet of agree with. Well, um, I assume that's your room and fine. Okay, fine. We'll let you go without, really All that's very good. But then what's the point? You know? Oh, you can answer that. Going. Going? No. All right, fine. Big on with you. Uh, I'll, uh, I'll get the next one. Ah, here. Okay. So, hernias. Why won't it won't have a hernia. Hernia? An emergency, Hal? No, but their complications are good ways of showing the problems that come about with bowels on. Those could be emergency. So might as well talk about, um, one of the hernia viscera protruding through a defect. So, um, stomach goes up through your diaphragm. Hiatus Hernia. Uh, the wolves, the holes of your deepen superficial will ring are still Peyton, sadly and bowel gets through it, Um, inguinal hernia. The wall itself of the rules of the canal are weak and allow something to push through another form of inguinal hernia. It's it's It's a lot there, but do I particularly care about her? News is an emergency. No. What do I care about? So if the defect is large, I'm the whole that have come through his large. I'm not to work because a large hole means that less likely that any sort of twisting or what have you is going to cut off blood supply or or something like that? Um, it's more easy for it to be kind of in a blood supply in a smaller hole. Just why femoral hernia is more concerning because there's a smaller, um, defect. Generally that they can go through on. They have a higher chance of getting this medication. Um, the ah, if it's been there for a long time, I'm not too concerned either, because if it's if it's been stuck out for a long time, not too concerning like like years because over time hernia of the hernia sac that starts getting a huge INS toe the wall outside. And so it's really tough to put it back in and keep it in. But that doesn't mean it's a problem. The problems occur when it first incarcerates, which means it gets stuck and generally new incarcerations, or what concerned me. Um, that in itself is in the emergency, but that's the reason to refer a certain strangulation, some sort of flow in this tube has been bugged because of this. Either is blood flow. So that's Kenya or it's the poo in it's obstruction. Let's go through skin your first what happens is, um, intense amounts of abdominal pain specifically there or maybe in the abdomen. If the part just, uh, just distal to the the actual hernia part's been, ah, been, uh, going to ski make. Um, they will probably get diarrhea because the parts distal to the hernia or the obstruction will try, and empty itself is the Is the bowel dies. There'll be some blood involved as well. Um, on even if you if it's been out for a very long time and and ah strongly for a long time. But you eventually competition and you pop it back in. If the pain doesn't go away with painkillers after 15 30 minutes, it still needs to be looked at by a surgeon because maybe was it's going to ski make, and it's become it's going to just die because we have been able to reproduce it in time, or the sac is still constricting it. So, um, try and put back in. If if it's printing, it's popped out and stayed out very recently. But otherwise, yeah, um, we'll get to Ah, that's generally the same for ah, normal balance. Kenya's well is. And without a hernia involved, they'll be extreme amount of pain more than you'd expect with the with the pressure that you're putting on their abdomen. Don't trust them having a normal active because of normal, because the lactate highlight that relies on the blood that's at the site of strangulation going into the into the rest of the blood supply if it's stuck there. And none of that like that is coming through there like it's gonna be normal doesn't doesn't help you. So don't trust the normal active, um, and that strangulation needs to go to theaters. They need to see if they couldn't save the bowel. That's a time sensitive emergency. The other one is, um, obstruction. So, with obstruction, um, maybe it's ah, it's just, uh maybe, uh, two and a rift. There's a twist about on D, uh, again, What happens is the part distal to it? Uh, Paris told is like crazy to try and get the bowels Working again doesn't happen, but they end up having a large out motion outwards. If they've got enough good enough kink they can't get gas through, then there's no slated automatically. This is important on the stuff. Proximal to the obstruction is gonna start filling up with with gastric juices. Even if they don't eat, drink anything. They swallow saliva and all that stuff, so it's going to start coming. Distended abdomen is going to come distended. There might be some pain involved. Eventually, you might start vomiting a swell on. That's going to be what makes us think this is an obstruction, the vomiting, the actual no opening bowels or no flatus for quite a few hours. I don't abdominal pain distention. Probably some risk factors to allow as well. Ah, 20 year old. I wouldn't assume Teo get bowel obstruction, basically. But an eight year old with five or six abdominal surgery in the past, far more like on the warts. Ah, with your elderly patients if they if you're thinking they've had this. Another thing keep in mind is four elderly patients. A lot of them Congrats, constipation, and it can mimic obstruction really well. They can feel unwell. They can start vomiting. They can be distended the way to assess it before your referral is to do a PR, you need to put a finger in the back passage. See if you can find any hard poop there, if you can. Then put something up the back patio where you give them laxatives to try and open the bowel up. Okay, if it's a hernia there, a swell on, do you think the hernias because the obstruction, then it's not really gonna be able to fix it. But if it's just constipation with a normal obstruction without hurting involved, try and open up from the bottom end before you do it from the top end. Because if if it is obstruction, so let's say the bottom and loosen up the food the food goes out for. Their symptoms don't result. They may still having obstruction. And if you give them laxatives from the top and you might call something called a structural perforation with perforation, which is basically their bowels Paracels like crazy go Ah, go ham. And then they themselves a part in that they have proof flying everywhere. So, um, so just do the PR first check of There's heart pill in the back. Pass it um, if you find hard poop, um, if you don't find a hard poop, you don't find any math there either. Then you can do an X ray. Uh, I'm due x ray because that's one of the few reasons again affect rates to check for obstruction. And you're looking for radiological signs of directed bowel. Have you generally is going to be. They're generally if, um uh and then with that, when you have that image, you then it could be sued obstruction. But you should probably still refer to the students to the surgeons and then let them make that decision. They'll put me to assess the patient. Um, in the meantime, they'll probably advise you to do single drip and suck, Which is when you put a thick riles tube down there nose and and GI that decompressed their stomachs or they don't have unsafe vomits anymore. A lot of fluid go straight out there. It's on free training into a bank. You replace fluid back into them with IV fluids, maybe antiemetics. They still feel that setting in that I've used Well, um, Andi, uh, you can consider if they're doing really badly and they've lost quite a bit of fluid you can consider, um ah, a catheter to a monitor. Urine output for a strict about Put monitoring. Um, with the fluids. Don't forget, you might need to replace electrolytes. They'll probably to go into the surgeon. He decide. Do they want to try therapy to gastrograph in? Do they want to take him to surgery there? And then I won't have you The general. The adage is, don't let this arm go down a small bowel obstruction. But I'm not the one seeing your patient. They'd see your patient being decide when that surgery happened. So yeah, so I need to refer to those surgeons. Probably let your bosses know as well, but the bosses don't need outside of the advice. I mean, I don't think they were too much more than they add in terms of advice there, um, infections, intraabdominal infections. And that's why this image is important. Um, so like I said, it depends on the layer of the peritoneum being being irritated as to whether they localize it. Uh, right. Lower court and diverticulitis. Right. Upper quadrant. Biliary system. Right. Low left, lower quarter. And I particularly qualities. Right? Learn quadrant. Appendix. Um, there's a general gist. You get, You do a history. You an examination. Do the 80. You give him analgesia. Ah, this thing about don't give analgesia because it might change the clinical signs for when they assess it. No, no. You give analgesia, um, on IV fluids in your for two surgeons, and they'll probably ask you to give antibiotics in the meantime, except maybe for a pen, decide if they want to make sure it's a good going appendix size, and they want to take it out, but I'll be up to them. They might also want a CT scan to be able to find out the source of it. And they might also want a CT scan for the instructions as well, because they want to find out where the cause of the obstruction is. But that's gonna be for them to decide. Not for you, you know. You know your state, right? Good bit of chatting, is there? Uh, let's see about going to next questions. Just so we have a look of the lost results. So femoral hernia. 48 of you. Ah, 27 set inguinal. So just so you know federal hernias are more common in women than men. That is true. But if a woman comes in with a hernia, it's more common for it to be an inguinal hernia van. A femoral hernia. That is exactly what factor was trying to get that in terms of I'm trying to trigger. I was, and I got 48. Proud of that? Ah, leaderboards right now. M o Piglet, you've gone. You've gone into into three. That's cool. That's the third position of great great stuff, guys. Um, okay, abscesses, lump. That's where I talk about the breast. Breast abscesses, breast lumps, perianal abscesses, actors in the armpits. That's one thing, uh, with the breast. Um, do not sticking the limit if you're not sure if it's an abscess or not. If it's like between, you think it would be at risk for chemo tumor? Don't stick in the limit, because the moment that you do stick a needle, it goes from being possibly stare. I'll to definitely not sterile, and you'll probably get after, and they have their own risk. They might need an incision. Drainage. If it's just a chemo treatment, might just go away on. So if you get a lump, assess it. 80. Refer to surgeons. If it's if they're thinking it's cancer, they'll say, Send it by MG T. And I think it's infection. They'll season during that admission. Um, if they decide is an abscess or if it happens, just found anywhere. Really? Perianal under the armpits, growing ghost, urology. Anything else? Generally, Genser, Just some hospitals. Um, limbs are gonna be, um, orthopedics. Uh, so it depends on your on your guidelines there, your local guidelines. But it's gonna be ah, course of antibiotics. If they're tiny, maybe I'll school. They get. Otherwise, I'm sort of drainage of the abscess, either with or without an incision, maybe just a fine little drainage instead. Um, for abscesses, to be different from suddenly like this is not just a bad infection. There needs to be a point of actual fluctuance. It needs to feel like there's a liquid underneath. Just the Borgia Dema of cellulitis isn't the same thing. So you talked to be poking at one point. Generally, the the part that's sticking out like yep, that feels I have fluid in me that could be quite tense from the fluid, but it's okay question for Fad. Um, are you still there? Yeah. You were you gonna say federal or inguinal for the last one? Well, I like kind of get I said you're trying to trick me. Femoral is more common in females, but it's not the most common for Well, you know what? Let's see if we can get you on this one. Yeah, I'm not gonna commit to anything. Make commitment issues are not the first time I've heard eso does the bilirubin have to be raised in cholecystectomy. That's a nice little image there. A small. But does the bilirubin have to raising cholecystitis? What do you think? Yeah, well, Curtis is status is an inflammation of the gallbladder. Uh huh. On bilirubin is you know, if it's raised, it's an indication in this in this kind of situation is blocked. Biliary tree duct. They all distinct things could coexist. Could know so well, this the question is pretty specific. Doesn't have to be right. Was your answer. Well, no. Uh oh. Okay. I'm going over. Your commitment is strong. I love it. Will get to that in a sec. Yeah, You weren't leaving me alone, so No, no, no, this time. Exactly. All right. Um and we'll, uh, make sure you you saw a couple of those funny stories, because those later question they're gonna be Austin Note from you. All right, be gone. We'll go over the onfi. Thank you. All right, so, biliary system. So right, according pain closest itis or, um, could be a send in cholangitis. We'll have you the important part. The emergency part off the biliary tree. So perfect goal. Better? Sure Prefer to surgeons. We'll check it out if they're really accept it. We should probably come sooner. But a patient The thing I want a hammer home. A patient that has biliary obstruction with the stone is stuck there in the bilirubin, getting worse and they're febrile. And the Friday and the ercp guys gonna come in on Monday. You have to think, Should they really be waiting three days for that? Ercp probably know if they're getting worse in the obstruction getting worse. So if you note this, let your boss is no too. So you can think about should we be thinking about transferring this patient somewhere that can do any recipe over the weekend? That's the emergency. Is it specifically surgical? Yeah, maybe. No. Maybe general management by the medics. But that is there in surgeons do love the biliary system. Quite four co cystitis is I wouldn't closet a zar emergency. Personally, it's just infection and ah, have issues. Goes along with that, Uh, surgeons love ultrasounds for them. Overnight ultrasounds are available. Get CT scan instead. If you if they're quite unwell, running by your boss is because they might cost more. Um, there doesn't need to be biliary obstruction of the CBD for it to be cholecystectomy. It could be a stone. That is. Let me put my master just the neck there. Now the bile is made up here and it travels down. It goes into the bile into the goal bladder to hold it, but it doesn't make it there. Um, it's made there. So if the obstruction is anywhere along here, they might have a slight raising bilirubin. But maybe not that high. If they have anywhere down here, they'll have a really big raising bilirubin. Uh, and that's where the That's where the concern comes. Uh, anything else covered with antibiotics? Um, some hospitals for closest. I just They just give antibiotics wait for it to die down. Surgeons see them in an outpatient. That's why I don't class as, ah, as an emergency. If they're having quite a bit of a hard Oh, pain. There some paraffin is, um, to you can always get direct chest X ray to look for. Ah, any free air under the diaphragm. Not very specific, but it can help nor a sensitive story. But it can help to see if there's a perforation there. Um, and surgeons get more involved if there's other complications, like pancreatitis will have usual. Um, right next one is believed I'm doing the top. Doesn't Upper GI bleeds? That's a medical issue. Generally, it's treated with medic because then doing endoscopy where they can find the bleed and treat it well, um, I'm going to about lower job, please. Uh, just so you know, for the upper drive leads Ah, risk ratifying score generally done with the black for score to find that one mg cal in that different people have different guidelines on which cut off they have for for when, when they industrial patient the based on their blood work or ah, for lower jaw bleed as long as it's not straight. Melena is generally goes to the general surgeons that do you do a PR to check if there's if there is an actual PR bleed on going on. If there's a mass uh, causing the bleeding in the rectum? Because, ah, a lot of time the PR The PR bleed indicates there's a There's a mass in the direct No, all the time could be doctor. If there's a concern about stability that we want to reverse that and coagulation or give them, um, give them blood or fluids. But the ah, you're colleagues can cannot that I think I think Dan Tyler just joining hey down will come to you a little bit, buddy. We're just a little bit behind right now. Ah, let the surgeon knows when let the surgeon know when they're simple bleeding. If it's not getting better, let them know again, as they may want a CT angio to find out what the source of the bleeding is to see if it's amenable to amble. Is Asian of things operate on it, um, is rare. We take a patient of doctors because of PR bleeding, but PR believing is definitely the surgeons domain, so definitely refer to them. When you find them off off, you do a basic assessment. Let them know and get Imagine plan for them. Larger conservative. Generally gonna be a flex Sig is an outpatient pancreatitis. Not gonna get into it. It's Ah, People generally don't get them in the hospital unless you didn't. Ercp of which point you're looking after this patient and you're on the gas, You're team. So that's how you'll know what to do with that with pancreatitis. Um, just remember, do your eighties send off a malaise with with the rest of bloods that you do on feel comfortable giving, giving people fluid because they get very leaky whatever your dentist. And that doesn't mean they're fluids in their vessels that could just be leaking out into the interstitial. Everything like this. It's unless it's a complication. I wouldn't classes emergency either. It's basically infection of the diet particular disease in the left lower quadrant. So sepsis, same risks of ah, rest of ah, abdominal infections. Perforation. What have you there? Parasitic. Might want to get a CT scan if you think the infection's from diverticular disease. Uh, so the infection is diverticulitis thing. You refer to surgeons just so they can know about them, but I wouldn't cost that specifically is an emergency unless their septic IV fluids analgesia antibiotics. All right, we're going to next question. So this one, most people said no, I would agree. Uh, on the leaderboard has J p of the top right now. Good stuff. O f one hopeful getting up there. Um right. Question five. Classically, how many pees are there in acute liver scheme Of fact? I'm not gonna know. Gonna bring it on this one. Don't worry. Um, but while you guys have a think of that, let me start that question up. Don't worry if I'm I'm no good at bringing this one. It's okay. We're running out of time. Um, well, you guys think of the number of peas, Teo indicate a cute little, um, ischemia. Let's talk about the rest of stuff. Triple A, um, unlikely journey. More like they'll present with this, rather than it'll happen during your admission. DVT's generally a medical rather rod in basket Lor pe's same thing, generally medically treated rather than basketball, might be complications that vascular guys get involved with. But that's not the initial back. So it replaces. Thought this violent killer, because they show up is a lot different Stuff is like an unexplained abdominal pain may not always feel that post hole mass things that my clock you on to the fact they having a rupture Triple A ah, previous CT scan shows ah shows on a routine aneurysm already. Ah, depending on where the the aneurysm is, they might have lost blood supply to the gonad. So testicular pain lost, but to the kidneys show a K. I spoke to the femoral, so ah, limits chemo. Uh, both sides, both sides or one side. It could be, um, if you think it, you get a CT scan. Let your boss is No, because you need to talk to the vascular surgeons on your boss is probably have a chat with you patient as to whether they want surgery or not. They might know if the patient, because the survey yourself is very risky. They can die from the surgery, so they need to have a chat with the patients. Do you even want surgery? Um, if they say, Look, I definitely don't, then you could probably save you a trip of going to another hospital or transfer into another ward and just let them be peaceful. But that's between you and your bosses. I know saying that should be how you treat a patient, Um, right acute, lower skim it limits scheme. It's rare. Have only seen it once, Um, but but it can happen to your patients. They are pretty morbid that they'll generally quite more, but already if they're older, Um, there are six peas. No, all they need to be there. Some of the quite late saying late state signs. So pain pallor, paralysis, the late stage paresthesia or lost sensation. Early stage pulses in a pretty cold leg, perishing the cold. Maybe the triple A causing causing obstruction. Femoral. So, um so exclude Triple A on ah, assess for the pulse. It three pulse is in the in the lower limb behind the knee dorsalis pedis and behind the medial. Uh um, medium and the oldest. Um, And if you can't find them, then let the well, if even you can or can't let the vascular guys know on. It's a time sensitive one again being to get there quickly to science. See If they can save the limb, they might ask you to do a heparin infusion while you wait. If that's the case, are some specifically for the dosage and the rate and what have you Because, uh, it's time sensitive on you don't have time to be fasting around trying to think. What is this dose or what have you just asked me? Probably no better than you do. Oh, write urology. So four things with urology. One. Retention patients feel like they need to people they can't get a bladder scanner. The bladder scanner sometimes finds ascites and thinks it's a full bladder. To keep that in mind, Um, put the catheter in. I have three tips there. That's a team and tip. Just correct it. That's a Foley tip. That's a normal one. We use three ways or with hematuria little bottle nature. If you having trouble getting this tip in, this curve tip gets into the prostate lot easier and men so and they're kept in theaters. Whether you do urology. Um, so put that Kathryn. If there was a material before the retention, then they might. They might be hematuria that's causing a clot that's causing it. So put a thick three way I couldn't find a thick three way. Those Foley's aren't thick enough. Ah, they're general is a bit more firmas Well, but a thick three weigh in on with that one. Uh, so with normal retention, you'll just take out a sample. Ah, send it for M C and s measure the residual volume, which is how much comes out the bladder and then eventually get talked during their admission or later on with hematuria. You've put the cath the catheter in you push 60 mills and hard. You pull it out, push it in, pull it out. Your job is to break up the clothes to try and suckle the clots out. When it starts running without clots, you set up irrigation, Let it go. Let the let the urologist know if you put 2 to 3 of those syringes in and you just can't get them out and you've tried doing maneuvers or you move around a bit, call the urologist. They might have some tricks on their back to help you out with with breaking up those clots. Or maybe they just have to get involved if they're losing blood recess without with with, uh, part of the fracture of the shocking stone. This is something that people go to surgery for overnight obstructing stone. Maybe you can wait till morning. Paul in the practice, if it's managed by medics, are sometimes sometimes urologists. But if it's both together, they're febrile that your your urinary colic, your tear it colic. Sorry, you did a CT scan found an obstructing stone. Signs of obstruction on the CT signs of inflammation. Urine dip is showing. There's an infection going on. They're febrile. Ah, you assume it's part of with truck. And that is something that people go to surgery over night for. So that is something you definitely have to refer to religious as quickly as you can. Probably IV fluid. Recess. Um, analgesia on antibiotics while you wait. The antibodies won't work, but they can't penetrate stone well enough. But they can help stabilize the patient a bit. Lost one testicular torsion. Not gonna get into too much. Your patients could be 80 not 18. So the chance of getting torsion is a lot less. The testicle survives for around six hours after pains. It was longer than that. Then the potential is probably dead. There's me, a whole host of other different diagnoses for testicular torsion. But if you're thinking is testicular torsion, it's. I find it tough to diagnose myself of this point so I would have a chat with your bosses. You're looking for Bell Clapper signs of the testicle being like this one goes like that. It's hard, markedly higher than the other. And the cream Esther reflex is absent. Um, but if you so if you think it's testicle torsion, let your bosses no um, neck fascia for me is gangrene lost two things. Um, so very time sensitive issue. General surgery is involved unless it's around the scrotum, which is 48. So then it's urology. They need to go immediately to fitters for debridement. It's not just a bad skin infection, so, but it is a really bad skin infection that's not really quite bad, but it's not just that they'll be. They might be some surgery. Emphysema. The skin may not be black. Is may not gonna cross it. It'll just be red or really dark. Brownie. Dark, dark, purple. Ah, they may start losing. Sensation of the skin starts dying, but if they have a sensation is still early stages. Um, there may be some cool dish water soap coming out from some sort of sore something that's a good indication that the next, uh, they'll be very septic. They need the IV fluid resource. Antibiotics. Analgesia Need to go to theaters. Last one powerful most is someone's put down a catheter and hasn't put it back. Hasn't put the foreskin back again. Four tips to fix it. Number one. Squeeze the glands. Try and get the blood out of it so that it can make itself smaller so it can slip over. Number two. Put ice packs on the glands again just to bring them on around. The foreskin used to bring the swelling down everywhere. Number three. Put your fingers like this on the glands and squeeze the glands between them. So you're squeezing the blood out and then put the little tips of your thumbs underneath the foreskin. Use your other fingers to loop the foreskin back over the glands. Number four. Use up to Luke to try and help any of those motions that doesn't work immediately. Call the urologist because if they lose the if they lose the head of the Penis is very distressing, right? We got a mad I should be because I know I'm running over. I'm very sorry. Okay, This was the last question. Most you guys got it with six piece. Good job. Last question, guys. Who's Who's the head? F one hopeful ass, Right. Good stuff. Um, last question. You're on the You're on the ward around your boss, Your consultant ask you Do you want to be a surgeon? Hopefully through medical. You've learned the correct answer to this. There are to possibles on. That's basically it. That's my talked on Fatima. Yeah. Um, but, I mean, I'm done. I'm, uh I'm talked out. We'll look at this in a sec, but do you want to say anything else? Um, no. Nothing toe talked. You said obviously have given us a lot of good, useful information and tips. I've learned a lot. Definitely. Um, just just before you have the quick talk from being me, just, uh, remind you guys that we really appreciate your feedback. Please send it over to us. You can use the cure code, or the link will put it on the track as well. Um, Like I said, we're trying to continue. Only improve these every week. Um, you know, if you've seen, we've tried to act only the feedback that you wanted. Some polls. So, you know, Did you think it worked to do any other improvement? Anything you like? Um, it would be very helpful for you and also for us. We also need it for portfolios and things. So, um, please, please send us some people. Um, and then I think we can do maybe the questions after after it and yeah, maybe your let me just Ah. So, by the way, they also that one is, as you well know. You say either yes or possibly just so that you can still get to do stuff in in every ah application. Every thing you do on the winner, by the way, is F one hopeful. Good job. Thank you very much. All right. If I do, I'm gonna go mute and ah, listen to dance and talk with you. I was off on hopeful along, not take. Okay. I cannot share a mystery mile. Every participant is sharing. Okay. I'll just wait my turn. You take like like, a month. Okay, should be able to see that look good. Now, six. Um, so, yeah. Eh, So Ah, hopefully there's been a few links posted in the chart. Um, so basically, and there's a cure coat on the screen and see, um So basically, if you sign up, Teo, hear from us from the being made, by the way I'm using the QR code on the screen or the link in the chart will send you send you a free digital sport back. It doesn't mean you're signing up the membership. It's just a free support back from us to you, regardless of whether you remember not so that with that you get sort of employment guide, which would be useful. Looking ahead to f one, we negotiate the contract so we know what should be in it inside out on this thing, this guy. So it breaks out down. I would also get some of our next talk it and and some other bits again, doesn't have you know you're a member or no, it's just freeze off guide from us to you. This time of year, you would use the CIA's out, and we have lots of freebies and pens that kind of stuff for you, but because you're gonna be there, it's just in the way of giving you some stuff. So anyway, that the QR code is gonna be the top corner from my little bit if you haven't done it yet, you could do it while I'm talking about their mind on yeah, so cracking on. So I'm done. I'm from the b m A r. Talk to you really quick about membership. You may have heard me speak before, So I'm sorry if you have um, sure, you're you're members or most of your You've been a member at some point, so you know pretty much what we do, um, Or yourself gets. Remember, as the trees is a little bit of pressure, and I will see my friend out something you s So we have other trade union and fresh know Association for Doctors and Misuse in the UK, we added, the voice of profession represent you individually, locally and nationally on all the issues that affect you. So we get this confusion quite a bit, but we know in indemnity companies, so we're not like m d u m ps. We don't deal with patient complaints were here. Somebody took after you're working conditions. So things like your pain contracts your wellbeing. Also your pressure on supplements. So we understand sort of things you might encounter, particularly when you become enough one on we can give you advice and support one on any issues that might face. So this could be anything from from working hours to relationships with seen your star for any responsibilities you have the, you know, necessarily comfortable with. So she keeps the mind. We could take some of the pressure off you have. You're facing anything if you feel with the sport with. We've seen most things before, particularly if if if one's on, there's not much to weaken we can't help with. We have relationships with everyone, every trust in the in the UK on we have employment advisers and industrial Asians officers based. Every trust would always have someone in person you can speak to most much of the moment, but soon enough. So, yeah, we're here. If you want to reach out, there's anything you need to help with your support with, um, so very important thing that you gonna need soon. You may have heard of our contract taking service, which can say you some time and attention. Quite bad. Money s Oh, yeah, probably the key to all of ours that you use this year s. So we would take your contract in five working days comparing it to the the national model that mean ago she ate it. And if there's anything wrong, we can help get it sorted out. S o trusted. Always mean to, but But they can step in salt. Extra things here are now or change the wording to me in the opposite of what it should be. We've seen it quite a bit. So we try to make sure your contract's correct and you're getting paid. We should be, um, so scarily scary. Other day, 20%. The contracts we checked for for ah last year were incorrect. So one in five of the contracts that was sent its way to to higher numbers, far as we're concerned, s so it's good t join us, be of the BMA, and let's get this the check it preferably before you sign it. Um, I could say at this point membership is will be the same price is finally issues until October. So at least even in July, you're still only paying 3 lb mom to be a member to be in May. But I'll go in tomorrow that in a minute, in a minute. Um, we could also check your your rotors compliant. So you use our roads checker. So with that one, um, it's seven online to where you put in the information about your rotor, and it'll faggot to as it wrong again. It should be pretty sounded. So we hope that you won't have any issues. Um, as you guys. Ah, family is a moment you're actually eligible for the weekly subscription to the BMJ. So they put the proper doctor version s so you could be getting this every Friday of you already. Remember you just if you're not getting it and you would like it, just give us give us a ring on our general number or email and just say this is my address. Such wanna make sure. I thought I could get this from now on, because it should. It should be free to you, but it's not been thing. Um, you can also stop receiving the paper copies if you can them. Ah, and you can just like because you you guys have or just got access to be in the BMJ up anyway, So you can just read two copies as and when they come out on your phone on dull the old copies of one as well. Um, being a member, us to get access to our clinical with non clinical trials. So you sure you've heard of BMJ Learning So has over 1000 clinical with non clinical models? Eso. So there's a lot of good stuff on their stuff, which is good for helping complete your feet portfolio when you begin f one. Um, it's all very interactive on. Do you keep up today? Um, and there's also lots of audio and video stuff to keep you sort of more stimulated freaks. Margery Do is where you can. You can print off stiff, get us proof of learning which helps, and then later on, when you're after COPD points, not not so much enough one, but it's it's very useful. We have racking them up. Baby Library has thousands of e books and journals. First, research shows is which can access from anywhere. Um, obviously it's still closed the moment you took over it. But but you can access online books instantly for our website. So for your phone on the laptop, on way, have a series of webinars free for members through the years. Well, then there are lots of topics. And if you can't watch your life, you can just push it back on the man very early to be thinking about this parts. But if you're thinking about your specialty options, we have a special extra little which helps you get a picture of what suits you best. So that one, it's an online psychometric testing, which takes about 20 minutes to complete. Um, your last course of work violence questions then give you a pretty detailed report listing the specialties, the suits or the answer that you've given. I'm very easy to use. That covers all specialties on the reports really is very thorough. Lot of analysis and graphs and what not, Um, so we have some welding support services. Eso if any time you feel like you like to speak to someone about your well being, they're open 24 7 and and that's the all shoots and doctors. So, uh, that's that's regardless of whether you remember or not. Um, so you have the choice is to speak to a counselor or a peer support doctor is based on telephone. Um, we we offer video causes well on that. We're hoping to get back to fix the face soon. Um, and we'll make sure that you speak to the same the same person twice. If it's more on the singular cool eso again free, free to everyone doesn't matter of you remember or not for wellbeing services and obviously ah, it's completely, uh, the committee independent of the trust say, if you're doesn't write this up very quickly. If you know, you know I can't remember, there's not for because something about long today if you join using the link on a screen, the QR code on the screen or I think they're in the chat now as well, or yet the other comments. You'll get 10 lbs of our trust. This works for first time Jonas, or if you're rejoining, I don't see your free 30. Even come again is you wish. Um, but yeah, that so only have used that link there. So if you go to the website now and do it. You won't get that voucher. Um, so, yeah, 3 lbs. 66. It will remain for everyone until until October and then goes up to sort of 777 lbs after tax. Um, so, yeah, if you don't quite feel ready signed up. That's absolutely fine. But again, going back to what I said, it's that you can use the QR code on the screen. Um, and you'll just just sign up to be kept in touch of asthma. Me consult to send you timely messages. Just sort of things that you should be looking out for. A headache. That's it for me. Thank you for six. Free my bit. Okay, great. Thanks. Down for that on. Thank you. Got, um, an AB for a great presentation, I think was really informative. I'm sure we will learn a lot. I'm not We're running a bit late. So sorry, but, Fatima, whether any questions that we haven't answered on the chap there were you I don't know how much How much more time come, real food. Um, if there's any that, like, come up more than once, maybe we can quickly run through them. Otherwise, guys I'll post a link and email address on the chats. If you have any questions that haven't been covered, you can just send them to that email address and we'll be sure to reply to you with an answer. Okay, I don't I don't think anything's kind of been repeated. They were just maybe two or three questions. Let me want to do it. Let's just let's just do one, Uh, do the meanest one. Do the meanest. Um, I I'll just have the first one. Actually, that was also it's just just to clarify, um, someone say said, wouldn't you consider C spine injury before securing the airway? I eat. You know, you if if you knew that there was a c spine injury or but it was likely you wouldn't do a head still chin lift sort of maneuver when you're you're securing the airway, so just kind of make it crystal clear. Where where exactly? C spine, considering C spine immobilization is court. So the way it works in a song hasn't changed. Last copy, earthy less when you walk in. Ah, for trauma. You walking with your hands like this so you can secure the secure the head, and you asked the nurse immediately Put 15 liters on the patient, okay? And then you go and you try and do some area maneuvers while keeping the next stable on. Then you go to assess the C spine because a zoo, long as you immobilize the neck, you're not risking severing it, but the same so they're No. But if you move the neck, then you could kill them. But if you don't do anything, the airway can killed. So you don't do any airway maneuvers like sniffing the air. What have you that can compromise the C spine? You can secure the C spine, but you a wait until after you do the airway toe. Actually assess is the c spine safe? Yeah, I I think I think that was, um, important that you made the distinction kind of. When you're doing the airway, you you're already kind off taking into account that there might be a C spine injury. But you're not necessarily assessing what the injury is until after you assume there is until until operative that Yeah, Gianvi is popped up. I think she wants us to write it up. Sorry. Guys know enough time for more questions, but I've put the email address in the chats. It's info at mind the bleed dot com if we haven't covered anything you wanted to discuss, um, one more shot out for the feedback, please. If you could fill that in again the links on the chat, um, on. But I think that's it. Thank you again, Abbott. Fatima On. Hopefully you guys conjoined us next week for a weapon on hypo and hyper clean. Yes, it would be a a same time, but thank you. Been great fun. Thank you very much. By next goes