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Yes, Yes, yes. Um, good evening to everyone. Thank you for making our time again to join us today for today's teaching session. Um um, today we have I think, one presentation on medical emergencies. Um, this will be given to us by heartburn anymore. With currently live and waiting to give this wonderful presentation. Um, we've managed to sort out the issues from, um, Monday and hopefully going for won't encounter. Uh, any more of these issues? Um, I think it's important to also let us know that there are other presentations on the way. Uh, other presentations we are planning to deliver, uh, within the next coming weeks to months. The plan is to continue, um, this teaching sessions for quite a long period of time. And, um, it will be a good mix of everything. Surgery around? What? What we would be willing to learn. Um, So, like I did mention from the previous, uh, session, can we If you have any options on topics or things you would want to learn about, you could drop a message on the, uh, child box. Um, this presentation was built to start for 6. 20. at the moment we have, Um about about a few number of people will give some time. We'll give you a few minutes, Um, for other people to join. Um, uh huh. Permit me to say, Are we happy if this, uh, presentation for today's starts by 6. 30? Because I understand that a few people maybe, uh, maybe busy at work or trying to settle down and all that. Um, so with your indulgence, um, I would really appreciate it. You can start this by, um, 6. 30 The present. I see A is ready, and he's already on stage for, um, for for us to start. Um, thank you. Once again. Um, so if I could, um, call on, um, those present to introduce themselves. Um, so add you guys to the stage two. Um, say something on stage or if you're happy, Um, we could, um, those drop a message on the chat box. Okay. I can see. Um, my boss Mr. Follow up on the, uh, on the forearm as well. He's been a mentor of me. Uh, sorry to me. And, uh, has really been helpful for this. My strive towards, um, getting into surgical training, so I would appreciate if all those present at the moment can leave like a small comment in the chat box. So as we can better know ourselves while we're waiting on, um, other people to join. Thank you. Yeah. Thank you. Um, everyone. I think we've given enough time. It's time for, um, all those, um uh, other people to join. Um, So go ahead with that presentation now, and I'll be leaving the stage for opening them all to give his presentation on. Um, so we call the emergency, uh, even more over to you. It could be, um um what about the state that open works? Uh, currently in the in the setting. I'm sure he will give us a very good introduction to himself before the presentation. Um, hi. Good evening, everyone. Can you all hear me? Yeah. Okay. I'm looking at the chart box. Yes. Okay. Um, yeah. So my name is, uh, been a more a bit of background. Uh, my name is, uh I work in any in Epson and sent him the hospitals. Um I mean, any clinical failure in any before I start. I want to I sincerely think Bernard, for organizing this teaching sections. Um, as you will. As you all know, teaching is very, very important. Um, as a doctor, Um, certainly as any doctor that wants to go into surgical training of any sort or any any doctor in general need to be very well good in teaching. Um, because it helps in your clinical development and certainly is very good to put on your plate full year. Uh, I want to thank you once again for organizing, uh, these teaching sections. Um, So how do I start surgical emergencies? It looks like a very broad. A very large, um, topic allergy. Know we have to start with. So when you had called me to give this presentation now, I asked him why. Surgical emergencies. This looks very broad. How am I going to finish that? But I decided to do something. Hopefully at the end of this presentation, we should be able to learn a few things, and hopefully, in subsequent, um, series, we can touch on things with interaction today. So, um, our objectives will be to understand what surgical emergency would be, um, be able to recognize them. Um, certainly make diagnoses, manage them, and hopefully be confident answer a few questions either working in the hospital or trying out in exams. So, um, the Royal College of Surgeons of England defined emergency surgery, um, as operations which require immediate admission to the hospital, and this needs to be done immediately or within 24 hours. Okay. And this usually is because of the threat of life, organ, limb or caused by trauma. So certainly this is very, very important to know that this needs to be very urgent and needs to happen real, real quick. So, uh, internist surgical emergencies are defined as emergencies, which require immediate surgical intervention to manage them successfully. So, um, surgical emergency is a very broad and cut across all sorts of all types of specialties. Um, so certainly we are dealing with things like airway obstruction. Um, if you have done your list, um, you will know that is always number one in in your earliest. So you need to assess the airway as weak as possible. And if there's any obstruction, you know that certainly that is an emergency. That is the first thing you need to do. So, um, so things that obstruct your airway need immediate. Um intervention so that you need to be. Start calling off your anesthetics and you start looking for your ent doctors. Um, acute trauma again is one very important, uh, surgical emergency that needs to happen real quick and need to start Good, um, as soon as possible. So this got across all specialties, so things like cardiac tamponade. Um, pneumothorax certainly need to be calling your characteristic doctors. Um, testicular torsion. Um, urinary retention obstructions paraphimosis, which you need to refer onto to your urologists. Um, academic societies, obstruction of bowel, wall values, peritonitis, which needs to refer urgently to the general surgical teams. Um, aortic decisions. Ruptured aneurisms. This needs to be treated really, really quick because there's also it's always a very big risk of catastrophic bleeding. Um, you need to refer very fast your vascular doctors. Um, it's also very, very important to note that, um, gynecological problems are attend. Really, really very, very common in any and certainly all women of childbearing age is coming with, um, abdominal pain and abdominal symptoms need to be, um, taking into consequences. And so you need to take a very good kind of kind of gynecological history. So, um in the ending. Certainly. We hear people asking women of your last menstrual period bleeding history. Um, that is to rule out of the car problem regardless of whatever their periods into the emergency department weeks. Mhm. So, um, this diagram I have here I don't know if if you guys can see this picture here, So, uh, this is a depiction of, um yeah, Thank you, Bernard. So this is a depiction of how urgent, um, surgeries need to be done and how immediate and how fast it needs to be done. And there's this triad system, which has been by the timing of the acute scare surgery class, which could kind of use color codes to do, I mean, how fast and how quick. Um, and I just had surgery needs to be done. So obviously the very first one is called and red, which is produced, which require, uh, immediately life threatening surgical intervention resuscitation. So this will be your bleeding, bleeding emergencies. So your acute trauma, Um, your vascular problems like bleeding and you're regimes. Um, they need to have immediate operations, which is life threatening, so it doesn't happen immediately. Some other surgeries are color coded in yellow. Or this this type of yellow, Uh, here. So these are surgeries that need to happen within one hour, and patient needs to be optimized face before surgery. So things like herniations perforation, spirituality for sepsis. Um, and this is how the the color code goes down all the way down to the blue ones, which maybe not very immediate. What still needs to happen within 24 hours. So things like secondly, the laparotomy needs to happen between 24 hours. I remember from our definition, you need to happen immediately or within 24 hours. So without further ado, let's go into a case based discussion. Let's see what we can do with this case we see here. So, um, a 45 year old female presented to the any with a history of generalized abdominal pain, she also presents with the vomiting. Um, she described the pain has been stabbing in nature. Um comes in waves intermediate in nature, which is what she presents the any. And you're working either as an ent doctor or even called to review as historical doctor. Um, she has a past medical history of the neuropathy, which she did 16 years ago. She also had a cholecystectomy two years ago. Um, when you examine this patient, she had tenderness in the periumbilical area. Abdomen was not detained distended. Her rectum was empty and she had thinking about or sounds, um, you did not hands over the observations. I notice, um, your observations you have on your on your right hand side. So what do you think? Um, So if you have your thoughts about this case, can you please put it in the chart box, please? Can you put up the good? Uh, yeah. Thank you. Just in my face. You know, mhm. So I can't see any messages of Bennett City possible intestinal obstruction. Very good choice. Any other. Any other place to any other comments on the chart box? Um, there is a Juanita small bowel obstruction. Brilliant. Exactly. So, um, if you look at this case already, um, it's more thing is a lot of things already in your mind when you see this patient. The patient came in abdominal pain. Vomiting. Um, the intensity is college in nature is stabbing is highly significant surgical history with two operations in the last 20 years and Certainly observation would make it a bit worried. She's tachacardic. She's, um BP. BP is slightly on the low side. So this supposed to start ringing in your head that this is actually emergency and recent things need to be done immediately. So this brings us today, uh, the topic for today, which I've chosen among all the surgical emergencies, which is a bowel obstruction Good One, doctor. A daisy Rico. So, uh, bowel obstruction is defined as the mechanical or functional obstruction, um, of the intestine, which prevents the normal passage of digestive contents. Um so is divided into the bowel. Generally is divided into small or large bowel. Uh, so anything which is mechanical or functional, which is preventing the normal flu of contents either gas fluid, food or fluids is is classified as bowel obstruction. Um, it's more chemo epidemiology. Um, bowel obstruction is very common in patient that had previous surgeries, especially abdominal or pelvic surgeries. Um, the big age is usually above 60. Uh, mortality is very high mortality about 17%. Um, if there's no intervention and is as high as 15% in in strangulation. So these numbers making any doctor become very, very worried, and you know that this requires immediate intervention. So what are the causes of, um, bowel obstruction? Um, so I think doctor and he had mentioned some of them. So number one on this list will be bowling boil adhesions. Um, both medications can cost up to 75% of offices or small bowel obstructions. Um, another important cause of bowel obstructions in the smaller bottle will be 10 years when they become incarcerated, Things like suspect intussusception. I find it very difficult to to pronounce into into suspension, which is, like, which is a telescoping of the bowel, Um, volvulus, which is, uh, twisting of of of the bowel around this midcentury, um, things like Crohn's disease, which is a very important positive factor for bowel obstruction and, uh, paralytic ideas, Um, and paralytic ideas. There is no mechanical obstruction. It's mostly functional. Uh, but it still causes significant obstruction. So, uh, it seems like being immediately immediate period. Post surgery can predispose you to having paralytic areas. Um, some electrolyte derangements. The arrangement can also predispose you to having paralytic areas is a very important to know that this is functional. While the rest are mechanical. Um, for us to have a good understanding of this bowel, it's very It's very good for us to remind ourselves of the anatomy of the bowel. So the small bowel starts from the Paris Paris of the of the stomach. Um, and all these round loops you see here loops of small bowel, which is the small intestine, basically and ends up in the in the second while the last big bowls start from the second and ends up in the rectum. So, um, direct the small bowel measured about 6.5 m and length. Um, this is very this is a very long tube, So certainly this is very important when you start thinking about the pathophysiology, which explains a lot about how the symptoms comes through. Be that in mind when we discussed the pathophysiology. So, um, for you to understand the management, um, the clinical progression of the of the illness is very good for you to understand the pathophysiology of the bowels. So, um, this diagram here depicts that. So this picture you're seeing here, this red tube here is the bowel. So let's see, Hypothetically, there is a mechanical obstruction here. I don't know if any of you can see my my mouse. I'm not very used. I'm not very easy to this platform, so I don't know if my mouth No, no, unfortunately, we can't see your mouth. Okay? Right on the right edge. Here you will see a black loop obstructing this bowel called labeled additions. So this has mechanically obstructed this small bottle. I'm a reminder that this obstruction this adhesion could be any of them cost of mechanical obstruction. So things like vocalise into suspension, uh, or anything causing the mechanical obstruction blocks off the splits basically, and air comes into the proximal side of this mobile and goes up all this way down to this admission. What happens? Because it comes to us a a place of mechanical obstruction. You find it difficult to go through. I remember your your small bowel moves in a peristaltic manner, so it moves in waves. We described which, which is the explanation for the quality pain. You have the small bowel obstruction. So, um certainly your food, your fluids coming coming here in peristaltic motion fashion and needs an obstruction so it comes, gives you abdominal pain, which is colicky in nature, then, because it cannot move forward. This the areas proximal to these adhesions start swelling up. They become dilated, and then sweets fluid starts to accumulate. Um, this leads to vomiting as well, which is one of the signs and symptoms of of obstruction fluids becomes to accumulate inside the bowel, increased bowel fleet and because of hydrostatic fluid balance imbalances. Um, this this this change or this difficulty for fluid to get absorbed into the small bowel, leading to sequestration of fluid in the small bowel. So what happens eventually is that, um, fluids don't get absorbed. Patients become dehydrated and leads of hypertension, so it's actually a visual cycle because the cycle keeps on repeating himself. So vomiting persist. It's, um, fluids, gets a place that gets the get dead space. And then, uh, there's a lot of electrolytes, hypertension and dehydration and ultimately can be catastrophic because it can lead to shock and fatality. So, um, I think I think I discussed this in the pathophysiology. So what you see clinical picture you see in our obstruction will be abdominal pain with this college in nature, mostly on the same team. Abdominal tenderness, on examination, Um, thinking about also sounds tachycardia and hypertension and ultimately shocked. And that's if nothing's happened urgently. So it's important for you to know that abdominal pain and vomiting, uh, earlier, very early signs while constitution is a very good sign. So, um, you've seen our patients in the any you've done, uh, you're taking some history. Um, you've done some examination. How will you investigate this patient? Because you need to make a diagnosis. So, um, I think one of the very first, the most important tests our investigation for you to do is, uh, the abdominal X ray. So abdominal X ray is a very important sue for you to make a diagnosis. Given the history you have, um, so you take a clean abdominal X rays. Uh, plain abdominal X rays are not very sensitive, but certainly is a very good tool. In the initial assessment of patients, it's suspected bowel obstruction. Um, other investigations you will do will be easy to use and use and ease where you check your electrolytes. Um, very sure. Looking out for things like a k. I looking at the creating into the urine's your areas. Um, do your blood counts. Definitely looking out for neutrophilia. Um, crp is usually raised in this situation. Um, another very important, um, investigation that everyone needs to do any any or any certain it will be your blood gases. And what you're looking at, your blood gas will be your lactic. Your lactics. Really? Basically, um, lactic being high would be a sign of, um, lactic acidosis, which would be appointed to possible ischemia, which would be also appointed to how sick the patient is. Um, so when you do your your your initial investigations, your CRP is you're using these your lactate. It makes you assess the patients and see how where this patient is. And then you make your plan on how to either refer the patient if you any any, or if you're. If you're a surgical doctor, how to involve the seniors or kind of plan Any definitely treatment for these patients. Um, so in your abdominal X rays, you what you need to start looking at will be some things that are very, very relevant to abdominal X rays. So it seems like a dilated loops of the X rays, um, every levels, things like that. Um I don't know if anyone knows about 369 rule of the abdominal X rays. Does anyone knowing It's not about that. Unfortunately, I don't. Okay, so, um, the traces nairu is one of the trials, so I mean, I think, um, abdominal X rays X ray general is beyond the scope of this teaching, but basically this mobile is supposed to be less than three centimeters. The large bowel is supposed to be less than six centimeters, and the second is supposed to be less than nine centimeters. So any patients we, which we have done an abdominal X ray you should be doing using the all these tools you have on your computer system to make sure the the loops of bowel bowels. And when you make sure that you have to look at across this room so any bubble that is more than 10 centimeters will be starting your bills or what's happening here and suspecting this and and potentially try to do, um, more superior imaging to make a diagnosis. So to make a diagnosis of intestinal obstruction, your ct, abdomen and pelvis, with contrast, is gold standard. Um, anyone that has worked in the any on the UK, certainly will tell you how difficult it is for you to get CT abdomen is done, Which is why abdominal X rays are usually the first line of, uh, cosmic diagnosis. But once it's been suspected using this rule definitely before anything, any surgery can be done on any, um, any serious intervention has to be done is to be confirmed using a CT abdomen. With contrast, so other emerging that can be done would be like a direct direct chest X ray where you're looking out for, um, levels under the diaphragm, which would be pointed to things like pneumoperitoneum uh, perforation, uh, contrast study with patient drink, uh, contrast dice which make you help me make a diagnosis. So I'm working in the hospital in an acute setting need to bear in mind all these investigations for you to make a diagnosis or for you to make a definitive plan. So our patient has had this abdominal x ray, and this is what the plane, which is what the films look like. Um, what do you guys think been? And I'm expecting you to answer again, but I'm trying not to answer been, I've been answering a lot. That's fine. That's fine. That's okay. So, what do you guys think you can You can put it in. It's out box. Yeah, right. Um, so moving on. So it's difficult for me to use my courses around this abdominal films. So, um yeah, Doctor, Um, SB you, which is small bowel obstruction. So a few things you look out on an abdominal x ray. So, um, small bottle is usually a centrally located. So once you look at the middle of the x ray, you start seeing this. It seems like look like it's worms, I would say, Um, so these are your circular foods, your valve league carnival controversies. What? That's what they call it. So what it means is that this, um, this is your small, small bottles. And what makes you do you need to measure the the diameter of the small bubble once it's more than three centimeters, and and you're just your lips essentially located, Uh, you think about small bowel obstruction, So, uh, yeah, I just I just see dilated loops of boils. That's correct. Yeah. So once you make the diagnosis, So if you're in the any, you should be calling out your surgical teams to tell them this is what I suspect. Um, so that they start planning a definitive plan for these patients. Um, if you're an historical junior needs, the colony of registrar is trying to work on these patients. So why? Why? Why cell count is high. Lactate is certainly concerning. CRP is also on the high side, so this patient looks accurately unwell. Still, how do you manage those patients? So management of this patient is, uh is very tricky. So first of all, uh, the patient needs a lot of fluid resuscitation. Remember? I said earlier, um, the length of the small bowel is about 6.2 m, which is very long. So certainly is if it's obstructed. There's going to be lots of fluid loss. So lots of fluid pool in the Lumen of the small bowel, making it difficult for the for the body to absorb fluid. So the patient is really depleted. And when the patients is representing, take a Cadillac and hypertension, hypertensive of low pressure being on the low side. Um, it said that when a patient is hypertensive, they've lost about six liters of fluid um when the when the When the fluid start pulling in the in the Lumen thinking about 1.5 to 3 liters. So certainly this is a lot of fluids, so the patient needs to have lots and lots of fluids. So if any any. Before we are referring our patients to start giving this patient fluids, put your white blood cannulas. Try to get your fluids in as fast as possible. Um, so management of this patient can be divided broadly into conservative and surgical management. So certainly seeing the patient in the end, the units starting conservative management immediately. Um, patient is a lot of pain. They need to have analgesia, uh, general surgeon give lots and lots of pain killers. Uh, patient is feeling sick. They're still vomiting. They need to be prescribed anti emetic medication to stop this medication. Uh, you need to start the compressing the abdomen, so there's a lot of fluid build up in your tummy. That abdomen need to be decompressed. So most of the time when you call the surgical team, if you're working in a small hospital, they'll tell you try to pass an energy, too. Get your brows tube inside, get abdomen, decompressed and then start, uh, making plans for either emergency surgery or any definitive management. Um, the surgical thing we are advised, um, so surgical management will include things like emergency laparotomy. So most of the times, because the most common cause of, um of small bowel obstruction is of adhesions. Most of them respond really very well, too. Conservative management and probably might not need to have a operation. But certainly patient need to be observed really very closely monitored, Real acted serially do serial X rays and, you know, monitor the patient to see that they're improving clinically. So signs of clinical improvement would be things like hatred getting lower than it was before. Blood pressure's increasing. Lactic getting, um, normalizing. I would say the patient might need you might just do very well on just, um, conservative management. Um, if the obstruction is of an unknown cause. So, for example, you've done your CT. There's no there's no adhesions. You have some chronic report on your CT scan. Definitely patient need to go into going to the theater to have emergency surgery and then figure out what's going on inside. Um, so inefficient patient can also benefit from from addition, his dialysis, um to remove. Um, they had adhesions. Mhm. So our patient had emergency surgery, um, for the child for three days and did really very well on on follow up. So, yes, we have done. We are done with mobile obstruction. Um, let's talk about large bowel obstruction. So large bubbles starts from the second from the ileocecal junction and ends up into the rectum. Um, certainly a few things. Management and management and clinical features largely similar to small bottle of shorts on with a few differences. Um, there are a few risk factors that principles people to having lb you. Um, so it seems like cancer, um, predisposed to having, um, like, bubble obstruction. So certainly anything that predispose you to having cancers will be a risk factor. So things like alcohol. Um, just like smoking unfortunately predispose you to having cancers, um, obesity, low fiber diets and processed food. All these increase your risk of having colorectal cancer, which would say, at risk of having lb you, um, some familiar some familial syndromes as well predisposed to having large bowel obstruction. So it seems like, uh, your limb syndrome. Your Adam Entous polyposis is puts you at risk of having a colorectal cancer, which ultimately previous positive to having lbs um, chronic chronic conditions like constipation's can predispose you to having lb you neuro psychiatric conditions like Alzheimer's disease. Um, parking seen, um, schizophrenia. Also predisposed to having colorectal cancer, colorectal cancer and black bowel obstructions. So, of course, it's like I said earlier. The commonest cause of large royal obstruction will be colorectal cancer and also things like Volvo use, which is like, which is a twisting of the next century, uh, intestine around the mid century, strictures from that particular disease? Um, inflammatory bowel. This is also pretty supposed to have any obstructions. So what are the clinical futures? So clinical features would be constipation. So, um, when we discussed earlier on with the small bowel obstruction, nausea and vomiting, most earlier signs and symptoms in small bowel obstruction whilst in lead level obstruction constitution is an early sign or will be, and we will be an early sign. So you need to be asking the right questions. You need to be seen to be ruling out in any patient coming, which are suspecting having a bowel obstruction. So questions you need to be asking the end. It will be. When did you open your bowels When you pass wind. Um, so certainly you need to have have a lot of patients with elderly patients. They don't have any idea. Um, about all these things, you need to be ruling that out of the action of this question. Because if you don't ask the questions, you probably not get, um, any good answer. So bowel opening, how frequent it is when that it was very important. Passing wind is very important as well. Um, one of the clinical features would be abdominal pain, nausea, vomiting, bloating. Um, you also have symptoms of, um, malignancy, certain things like weight loss, changing change in, uh, ball habits. Certainly this will be ringing bells in your ears, and you'll be asking questions as to, um, making suspicions of, like bowel obstruction. So management is, uh, management of liable. Obstruction is also similar to a small bowel obstruction, and so you need to resuscitate the patient with fluids. Given a lot of IV fluids, start getting your heart man solutions and getting it in as fast as possible. Um, start doing your X rays, Start doing your CT scans, starting your ears and use your CRP s and making definitive plants. Um, the abdominal decompression is also very important. So you get your MD to get aroused to put that into the competitor. Me relief symptoms. Um, prescribe, um, pain killers prescribe anti emetics Medicare patient comfortable trying to refer early enough to early on to the specialist. Get senior imports right on time. Get get it ready. Group group and see blood. Just in case patient is going to need surgery. And then you just try to be a good doctor. Basically, um, So, um, other management protocols would be operating management. So the operating management of this state of this patient like this a bit different from a small bowel obstruction. So, um, if the if the opposition is coming from a clear cost, certainly the patient is going to need, um, exploratory lap fruits and try to figure out what's happening. Um, some specific operations will happen depending on the type of or what is causing the, um, obstruction. So it seems like colon cancer diverticulitis. We require patient to have what we call a half months procedure. Um, um, segment of laws require a rigid sigmoidoscopy, plus flattest to in session and second of overuse require, um hemicolectomy. So, um, I think I think everybody should look up the difference between management of sigma marvelous. And see how viable, Because it's their be related, But the management is certainly very different prognosis. So, um, uh, prognosis is very poor. Is very is very, very bad. If there's a delay in management mortality, about 14% delayed, uh, compared to 33% when performed immediately. So certainly, uh, you see how fast you need to intervene to make sure that the patient doesn't die. Um, manage very well, manage to aggressively get seniors on time. And then certainly the patient is going to do very well. Um, large bowel mortality is slightly different because, um, most of it and like bowel obstruction, obstruction, coefficients of orderly in age. Um, risk factor is colorectal carcinoma, which sometimes will be advanced with metastatic. So definitely the prognosis is slightly bit poor. Poorer mortality is 20%. And the prognosis, um, despite surgery, um is still very poor for like, level obstruction. So there is a five year survivor of large bowel obstruction is at 7% which is not very good. But that is largely because, uh, correct. Correct. Er, carcinoma has, uh, does not have a very good prognosis. Yeah, and that's it. So, um, it's very important for you to recognize this, um, ball of shops and on time have a very high index of suspicion If patients come in with abdominal pain, uh, vomiting, constipation, try to do your X rays earlier on and make a definite plan, uh, if any. Any. Try to get your surgical teams in time to make a review. Um, if you're working in the surgical department trying to get your seniors in time trying to get a very good plan and then ultimately, um, uh, my ex patients very well, so that to to reduce the mortality morbidity patients experience. Thank you. Wow. Thank you very much. Hope enough for your presentation. Thank you. Thank you. You've actually I actually don't really Well, um, so I thought I had 40 minutes, which I try to go through as fast as possible because 40 minutes is not very. It's very short for, um, this topic, but, um, I tried to wrap through, which is why I would sound like a rapper. But hopefully a lot of you picked up a few things. Yes. Yes, I must say, for myself, I'm very impressed with how you managed to look at the topics. The topic itself. You were quite concise. You give the needed information. Um, like you rightly said 40 minutes is not good enough time to go through everything. Well, you brought out the key factors, and you made it obvious that these are the key factors. And I think that's what's important. Um, going forward, like with any other topic or with any other things we learned is always best that we, um, on our own read more. And honestly, I'm very happy with the presentation. And I've learned a lot especially devastating between the small bowel and large bowel obstruction. Um, prior to this point, in my mind's eye, ball destruction is about destruction. But you've clearly made that, um, obvious that they're not, and they're management protocols are not, um so Okay, um so feedback for I know Bernard said the have not used this, uh, Medrol before. I used to Microsoft teams and things like that so I don't know how the feedback think it works. Uh, but yeah, I still have a feedback phone for those, uh, for people to give me feedback, so use the Qvar. Could give me feedback. Um, so to improve my teaching. And hopefully I will learn from that as well. And yeah, give something better. Less time. Okay, quick one. The quick the feedback from do you think is something that will take a long time to feel, You know, um, so, you know, it doesn't take time, so it's It's a curable code. So anyone that uses QR code point their camera and it leads them to Microsoft forms. Um, once it's open in your phone, anytime you're ready, you can fill it in. So it's just probably, like four questions, so it doesn't take time. Okay. Thank you very much. Thank you for your time. Please. If you have any questions about what you've learned, um, today or about any of the presentations, um, so far, anything said by, um, open. Please feel free to act. Um, I'll give a few minutes to allow for our colleagues to leave some feedback. Um, while we're getting ready for the next presentation as well. And I also want to introduce my very big boss, Armento. I'm sure he's smiling. When? When I'm saying this, uh um, Mr Pollen, Um, electrical. He's he's a big boss. When I said this whole trying to get into surgery training thing, I know how much time and effort he put into providing me with the information, and he's currently with us. I would appreciate if he can just a mute his mike and say a few words, and you'll also be be giving us a short presentation on traumatic chest injuries. Um, initial management as well. Um, I think it's also important that I add that he was not supposed to give this presentation. Um, but unfortunately, we couldn't The presenter had, uh I couldn't make it. So he's He has stepped in again once again, a big boss, that is. And honestly, I'm very grateful. Uh, I don't call myself a big boss. Yeah, sorry. I'm just trying to, um, figure out how this thing works. Okay. Um, well, thanks so much better. It's been a pleasure in the end, I think we all started all this so that we can help ourselves, you know, and at least create a network through which things can be made easier for everybody who wants to do general surgery. Um, in the UK it was, uh, I finished a bit late from work anyway, but it was a good presentation about the basics. At least in managing. I'll say intestinal obstruction as a whole. So So that was a very good presentation. I think the only thing I will add now is that we're conservative management. What we apart from all the n G tubes and every other thing we do, we also give an early trial of gastro graphic, um so gastrograph in, You know, the It's kind of still the same thing that the radiologist used for contrast studies, but this is in a more concentrated form. It's been found to. It's osmotic effect has been found to reduce bowel wall edema, and it helps to kind of open up. I'll say, For those who have adhesive small bowel obstruction, it's been found to help release or kind of, um, release the obstruction, and we think it's because of the osmotic effect. So it reduces the bowel edema and that kind of on kinks, the adhesions or helps it resolve. So it's used in Usually some people wait for, like, up to 24 hours or 48 hours. But recent studies have shown that, um, you can even do within 12 hours, 8 to 12 hours of putting an n g tube, decompress the stomach and then just give the gastrograph in through the n g tube. And if it resolves within 24 hours, it means that that one is more likely amenable to conservative management. So that's the only thing I'll add there. Um, so the presentation. I'm sorry. I don't know whether people can hear me. Actually, yes, we can. Yes, we can, um, other people if you can type out in your comments section. But I think, uh okay, okay. I just want to mention Okay, So basically, when it comes to traumatic these I think the basic thing is about how you manage patients for those of us who work in the any. Now we see so many of these things. Um, traffic accidents, um, fall from a height and, you know, maybe attacks penetration injuries, which could be a gunshot or knife phones and so on So we've seen quite a lot of that. And basically, the main thing is, how do you manage this kind of patients? The first thing the first line of management is it depends on where you find a person, actually. But most of the time we see this person, these people in the, uh in the emergency unit because they've been brought in either by the helicopter or by an ambulance, the on the scene, the first thing they do is to go all the way to approach management of these people. And this is maybe, for example, process and also for real life experience is use the principals laid down by the A. TLS. You have to do. You start. For every patient, you must evaluate a B C. D. Now this patient has a traumatic chest injury. The first thing you want to assess is you have to make yourself safe anyway, before you start doing all the assessments, especially if you're in the field, so you make sure you're safe. Call to the patient the patient answering So you're already assessing airway. So it's airway. And if the person is talking to you means that the airway is at least patent. If the person is not talking to you, then that's when you know that. Okay, I have to secure the airway where you do depend on whether the person has also had the concomitant head injury. That's where you now have to make sure that you do the head sales. But in doing the head sales and all those things, you have to make sure that the person does not have a head injury, you know, because you can end up, uh, say severe in the spinal cord. You know, given the person that high court transaction. So airway security, every person talking to you find you're going to breathing where you assess where the injury is. So you have to expose the person properly, look at the chest and you assess. Okay, what kind of injury does this person have? Um, you have to assess the respiratory rate, how the chest is moving and whether they're crepitations on the chest. That's part of assessment of basically breathing, and you have to ask about it as well to see whether the air entry is adequate on both sides. So if you see an open wound on the chest. The first thing you have to do is to put a dressing on it, but addressing you put a three way dressing where you tape it on three sides, but leave one side open, and that's for people who have. You know, pneumothorax is basically, if the attention, or if it's a simple pneumothorax, right by putting that occlusive dressing on it, if you put it completely on it, you can end up converting it to attention pneumothorax, which you really do not want. And so basically what you have to do is to put that three way dressing on it. So at least the pressure in the thorax is not increased, because when a person takes it, if you've occluded it and the person has attention pneumothorax when the person breathes in and there's no way for the air to escape because you've occluded it. What happens is that the air is going to enter into the mediastinum and all and cause well, basically increased tension in the thoracic cavity because the air has nowhere to escape from. And that's what will cause, uh, cardiac compromise and, of course, death. And of course, part of this all this. Your assessments about the person's chest is also, um, making sure that the person doesn't have attention Pneumothorax at that stage. If you're in the field, of course. Watch all these movies where someone sticks a pen into the second, uh, intercostal space and all that, but the life saving thing and so on with the attention pneumothorax. If you are able to assess that and see that in the field, that's what the person has. Um, well, it's by sticking something into the second intercostal space. A pen may work, I don't know. But, you know, I've seen it in movies, but I've never done that anyway. Um, but what we're talking about is if you're assessing the person and, um, let's say the accident and emergency some of us maybe working in places where, um, you are called to assess the patient, you know, like you're part of the team and the team leader now calls you out and tells you to, you know, do the A B c. D. So we know it's a traumatic chest injury. Anyway, the status, of course, would have been called before the person comes. And maybe assessing the airway or will be part of those assessing the airway to see whether they have to intubate immediately. You will be part of the people. Assessing the breathing and all the breathing is very important anyway. And according to a TLS principles, if you do airway breathing. Fortunately, you have a team there that will also be putting in cannulas at the same time and taking, uh, blood for a group group and safe and cross match and all those things. But if you have to answer the question as the team leader, you'll be assessing airway breathing, circulation and then disability. You have to go in that a B C D order, because that's how a TLS does it. Um, so basically, with dramatic just injuries there, I mean, after you know the A B c D, Then that's the primary survey. Basically. Then you have to do the secondary survey anyway, which is still going through the same thing, but in greater detail where you go from head to two. Um, so that's how you approach any of the questions involving traumatic chest injuries. Now, when it comes to the details in particular about chest injuries, what you're looking at the simple things, um, with the chest injury depend depending on what cost. It's blunt trauma. You expect rib fractures, multiple rib fractures, which could cause a flare segment and, of course, further compromised breathing. Um, if it's a penetrating injury, like a knife, or so you may not have a fractured rib. But of course, then you definitely have, uh, like a stab wound or a gunshot wound. Something like that. You probably may not have a broken rib, especially if the knife under has gone through the intercostal space, of course, but then you'd have a hemithorax, definitely pneumothorax and long conditions. And unfortunately, if it's on the on the left side, you're going to have somebody with probably, you know, um, injury to the heart, which can cause the cardiac tamponade. So all these are things that you have to be mindful of, especially when you see a stab wound right penetrating injuries to the left side of the chest wall. What you have to keep in mind with traumatic just injuries is just remember your anatomy. If it's on the right side, you're thinking of okay. It's just the lungs, basically, but it's traumatic Chest injury it's a penetrating one. You remember that the ribcage the lower part of the rib cage covers the liver on the right side and the spleen on the left side. So even though it's gone in between the ribs, you can have a traumatic laceration of the liver if it's established or the spin on the other side. So even though you see some of the dramatic just injury, you have to be thinking of the person as a whole and the organs if it's on the left side. Of course, you're thinking of your thinking of cardiothoracic, of course, when it comes to the heart injury to the pericardium, cardiac tamponade and, of course, the lungs. So these are all the things you have to have in mind when thinking of that. You also have to remember the great vessels from, uh, and serially, if it's an anterior stab that somehow missed the sternum or it came in kind of from the apex around the neck area. You're thinking of the big vessels, and that, of course, you must involve cardiothoracic six, the the characteristic team. So basically your aim with initial management of these patients is just stabilization and um, and referring to the appropriate teams. If it's, um, if the patient has a pneumothorax or pneumothorax, which is usually what they come with, if if they're not fortunate, what you have to do is to, um, put a chest tube, of course. But the main thing is to make sure that they don't have any life threatening injuries like a cardiac tamponade. Attention, pneumothorax. Once you rule out these, these are the two main things. Once you rule out these life threatening injuries, it will be you will be It will be easier for you to get some imaging, so the first thing is immediate. So the steps are immediate assessment of the patients where you do your A B C D e according to um, a TLS principles. Then you want a diagnosis. You know, we know he has a traumatic chest injury. You know, the mechanism of action car accident, gunshot wound, or whatever it may be the first Next thing you want to do is do a trauma CT back in Nigeria, in West Africa, if they don't have CT scans that we do all these X rays and all but X rays don't really show you the depth of injury or what is involved. So you have to deal with a lot of you have to do a lot of examinations to actually find out what's going on. But here, stronger city all the way and depending on the mechanism of action, usually they just go. They just can everything head to literally, to to make sure that there are also no associated injuries apart from just a dramatic chest injury. So depending on what is found, um, on the CT scan, you know, and depending on whether the patient is stable, your patient is not stable enough to even go for a CT trauma city. Then they can do a fast scan. You know the focus. Well, it's kind of a focused ultrasound anyway, but what they do is they can scan the chest to see whether there's any fluid in there with the ultrasound at the bedside. And if they see that there's fluid in there, they just put a chest tube immediately. So, um, and then, of course, um, when the other people who are supporting would by then she the person who have a white bark and really in both arms and the IV fluids going up with, you know, the all the chest leads in to monitor the persons with the BP monitor to monitor the person's BP. They also examine her. I'll be there as well. They also draw gas is because you want to measure the person's at least the patients, the patients, the arterial blood gas to see how much a person is being oxygenated. So, um, after doing that, then when the person when the person is stable, then you can now do the secondary survey if it's, uh, long injury or lung condition after the initial management, where you've stabilized the patients putting chest tubes if chest tubes are needed. If yeah, then what is done now is basically the secondary survey where people take their time and actually assess the person from head to toe. And the patient's depends on which hospitality is may go under the orthopedic surgeons or may go under the general surgeons. So in that case, what we do now for these patients, if there's nothing life threatening that needed them to go to theater, What you have to do is how to, um make sure that they recover well. So people with hip fractures, that's where you have the anesthetic team. They can use lidocaine patches, or they can do intercostal or paravertebral blocks just to relieve the pain. Because if these patients, if you don't, if you don't get on top of that, that's that's one of the most important things in managing these patients. If you don't get on top of the pain, they're going to get worse because don't be able to take deep breaths. They'll get that electrolysis and then they'll get pneumonia. And you know, that's, uh, just decline. They will never recover. So if they have, whether they have chest tubes or not, the anesthetic team or the painting, they always call them. And the anesthetic team. They always give these services, like intercostal blocks, paragraphs about blocks to prevent pain for the chest. And, of course, then the physiotherapists must be involved because they teach these patients deep, deep breathing exercises and how to cough properly so as to ensure that you know the, uh to prevent heart electrolysis. Basically. And of course, the physiotherapy also help them mobilize because these patients are at risk of deep, deep thing. You know, um, clots because they lie down in bed the whole time you're in pain. So the physiotherapy, apart from giving them the chest physiotherapy, also forced them to mobilize as well. So management for them if they don't have any life threatening injuries that needs surgery is just basically all these little things. Pain control, chest physiotherapy, nutrition. If they don't feel like eating, put an N J tube or an N G. Yeah, put an N G on N J tube and feed them by force, because that's the way it's done. Um, if you don't feed them, they'll just not get better. And they'll be persistently in a catatonic state, which wouldn't help their recovery very well. Uh, sorry. It's getting a big dark hair, so I just put on the light. So I think this, in a nutshell, is just the initial management for patients and patients with traumatic chest injuries, irrespective of whatever would have caused it in. In the end, the mechanism mechanism of action is also important because it enables you to think of the organs that may be affected and what you would expect somebody who's been in a car accident. You know, back accident with kind of a blunt trauma to the chest, you say? Okay, this person definitely has blond definitely have lung conditions. We have a head injury. So it helps you to, um, kind of anticipate problems, but whether or not but in the end, the management, the steps of management is still the same initial assessment. Um, initial assessment imaging if patient is stable and if no need for theater conservative management with drugs from other teams, like anesthesia Nutritionist, Physiotherapy. Um, I think if you're not sure, that's just the initial management for these patients when it comes to the specific things to deal with. Um, yeah, the only thing I can think of is for people with hemothorax. There are specific guidelines on when you have to call the cardiothoracic surgeons, because if the person drains more than a liter of blood from the chest cavity when you put in the chest tube, you must involve the cardiothoracic team. So I think that's the only thing I can think of. If you've seen that there may be some injury to the the great vessels, definitely you must involve them as well. And so It depends on what's affected. And as I always say, even though we're looking at traumatic chest injuries, you must. You must also remember that, um, the abdominal organs can also be affected. So I think that, uh, well, initial management of dramatic just injuries in a nutshell. Thank you. Thank you very much. Again. Uh, chief, um, um, I would like, you know, you know, sometimes we don't give you have a life with, uh, on our on our is you. Well, I I honestly do appreciate your time your efforts to do everything, uh, you're doing here, Um, Just to add once again, because I know I've said this before. He wasn't supposed to give this presentation. I have a last minute. He volunteered to give the presentation, and I honestly, I do. I do appreciate that you he is part of the bigger picture. What? I mean, by the bigger picture, the plan is as much as possible to provide an avenue for, um, you know, doctors who are willing to get into surgical training, the needed sets of information, good avenue to seek more information. And he's also, um he also provides a lot of things before we came on to this platform. We've been using other things. We've had multiple other meetings, and I'm very sure a few people have called him from time to time to seek advice on a few things as well. Um, that being said, I also must thank everybody who has made out time to come for this teaching. Um, honestly, I do appreciate the time and the effort. You have you been putting in, um, to the station? Um, and I just I just want to appreciate everything. Basically, um, lastly, just to let you know tomorrow will be having to teachings, uh, as well. So, uh, we'll be having, uh, ulcerative colitis teaching. Um, if you can remember, for those of us who were, um, around on Monday when we started, we had some technical issues with that. So we'll be completing that teaching on Friday. More like, basically, starting fresh just so that we get the best possible knowledge from that. And also we'll be having a basic principles on skin grafting transplantation as well. Uh, please, um, invite your friends, invite your colleagues. Um, and I know as you invite anyone who is interested in learning a few things because I think at the end of the day, as medical professionals, that's our goal. Um, and I hope that going forward, we'll be able to host a few other things. Um, we'll be able to learn more. Um, um and see how we can help ourselves achieve, achieve that goal. Um, I'm I'm sure most of most of the people on this platform can reach out to me directly or not. I'm sure most of the people here can reach out to me. Um, if you have any suggestions, if you have any presentations, if you have any input at all, please feel free to reach out to me by the end of this group of teachings would be sending our feedback forms. Please be honest, um, in the feedback so that we can improve our ourselves and see what we can do for ourselves going forward. We're still trying to walk on a time and date for the urological emergencies teaching sessions. Um, once we have the information, I'm sure would pass it across, uh, once again. Thank you. Thank everyone who has made our time for this presentation. Um, and tomorrow we'll continue the good work we've started and we'll see how things go. Thank you very much. And do have a wonderful day and a wonderful night. Thank you. Bye. Just as just as you say. Yeah. Sorry. On on a last note. If anyone has any question as well, uh, please feel free to act or drop a message on the chat box. Um, as well. Or you can reach out to me. Um, outside this platform. Thank you. Bye.