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All right. Oh, we have. Oh yeah, yeah, it's good. Um George K and some people for me. So yes. So guys, uh let's not mention clinical like actual clinical case, I mean names of patients or you know, um id patient identifiers. Um Good afternoon everyone. Uh This is our new uh our next teaching session which is on the unwell surgical patient. It will be delivered by one of our registrars uh Saraz uh who's uh really experience and uh will give us a good overview and discuss some cases on uh managing uh the well surgical patient. Uh It, it's, it is kind of like the same approach or principle as crisp if anyone has uh done it, but definitely not a substitute and we actually encourage people to take the course. Um Let me share the screen for and Sarah the floor is you see that she would turn maybe one of the lights off the problem. Yeah. Yeah. Uh The other one. Yeah, that's fine. As long as we let, let me see if they if we screen the shirt appropriately. Yeah. Right. And then you use the, the the presenter you. Yeah. Yeah. Just guys try them because it gets uh disconnected a bit tricky. Ok? I, I'm gonna touch this. Ok. All right. So, um yeah, so as panel said, basically, we thought it would be quite good to go through basically at the acute surgical patient. So who has actually done the crisp course here? Obviously through her, anyone else? Ok. So that's good. Um It's, it's one of the sort of acute courses that's mandatory to do during your core training. So you have to do it before you become a registrar. Um But obviously it's quite relevant to all of you guys as well. Who are you managing surgical patients on the ward, whether it's F one or sho level or registrar level? Um We will basically go through some of the general principles that the course teaches, but I try to make it a bit more relevant for your guys level. OK? Um It's very interactive today. So I don't have that many slides. We're going to mainly chat about stuff. Um The deal is if you interact, then you get CBD signed off by me. OK. So try and participate. Um So have you done Crisp Panos. So does anyone know where the crisp course originated from? So it's the care of the critically ill surgical patient. Um But does anyone know why it started? So I only found this out when I was preparing this presentation today. So, um any fellow northerners here? No. So basically after the Hillsborough tragedy. So in Yorkshire where all of those Liverpool football fans died, basically, there's a surgeon from Manchester who developed the course and it was the first, the first edition course was actually sponsored by the Hillsborough Charity Trust. Um So after an inquiry went into the tragedy, they found that a lot of the patients um actually died sort of shortly after rather than at the scene, died shortly after in hospital from their injuries. Um And there was a feeling that um although they're probably unavoidable, uh there's probably more could have been done to basically manage these acutely well patients, especially when you've got huge workload like that, it was like 9697 patients coming into hospital. Um and it's trying to empower junior members of the team. So F one's HS to also take responsibility for looking after acute unwell patients rather than just escalating directly to a senior, you know, also doing basic things at the bedside that can help um prevent these patients getting worse, ok, while they're waiting definitive treatment. So when people think about surgical patients, we often think about that left image. So people theater the surgery itself. But actually, it's a lot more than that. It's about the sort of preoperative postoperative patient on the ward. So I found a nice picture of Kelly on Google images there that's Kelly without her, without her red red uniform um in the ITU setting as well. So it might be, you know, you're at the sho on nights by yourself and itu reg calls you because they're worried about surgical patient POSTOP who's just not quite getting better or the numbers are creeping up a little bit. Um And also obviously A&E so wherever you're seeing patients at the first point of contact when they come into hospital, OK. So in terms of the structure, so the idea is to give you guys a system that you can fall back on when you're on the ward, you're alone, perhaps your registers in theater, operating, um your regs off site at night, if you're the sho on call, um give you a basic system to fall back on that you can do while you're waiting for help. Um And also so that you don't get stuck and you know how to progress. So the crisp algorithm basically starts off with the ABCD that everyone learns medical school you learn is an F one. It's very similar to um the A to E that you learn generally for any other specialty. So that's the immediate resuscitation management. The point is to identify anything life threatening straight away, um identify anything that you can treat quickly um and stabilize the patient once you've done your A to e, then the next step is basically to do a more in depth assessment of the patient. So this is sort of the new area that you may not have. L so far. So looking at um the patient's history, doing a more comprehensive examination of the patient, looking at any available blood results. So not just the immediate bedside results, but also further investigations, looking at the drug charts. Um and then making a plan and deciding ultimately whether the patient is stable or whether the patient is unstable, um and needs definitive treatment. Basically. Ok, when we're talking about stable patients, you've assessed the patient, the patient's stable, you've done your init initial resuscitation measures. Um you can then make this daily management plan. So sure, basically, that means your ward round plan. So all of you have done ward rounds with us, what we're sort of sort of looking at day to day. So the things on the left are the things that you can think about. So what investigations does the patient need today? It can be biochemical. So bloods might be radiological, they might need um chest x rays, CT S nutrition. So, is this patient nil by mouth? Um are they getting the requirements that they need if they're not, then how can we supplement that? Um Are they likely to need enhanced nutrition because they're, for example, they've got sepsis or they've recently undergone major surgery? Um what their fluid balance is like? And are we measuring that accurately drugs, some analgesia on the chart? So, basically reviewing the drug chart. Um is there anything that we need for treatment such as antibiotics? Do we need to give prophylaxis, for example, delta par. Um, are they getting their regular medications needed to manage their comorbidities? Physio, looking at drains and tubes that they have. So, in particular, surgical patients will often have all sorts of lines coming out of them in various tubes and drains. Um, whether this patient needs to go to a higher level of care or lower level of care, do we need to bring in any specialist opinions? Um for example, referral to another team. Um and also all the way through thinking about what communication needs to happen to make all of those things actually um come to exist. So there's no point writing on the ward round note. OK, I want, you know, I want this examination, you need to communicate to the nurses, communicate to the patient and the next of kin. Um and also document properly as well. OK. So bear all of those things in mind when we're talking about some cases in a little bit. OK. So we're gonna, I thought for this, you know, a fairly well because it's something you will have done in medical school. Um I thought we could, I've tried to put this white board up here. Um So we can talk through at altogether basically. Um And I've put some prompts up on the screen to remind you of like what resources are available to you. Um Alex is kindly posed for a photo there. So we've got a nurse. We've got a nurse as well. Um, ok. So let me try and do this without getting crushed. All right. So we'll start with a, so opening up to the floor, we're just gonna talk through each one about what things you're looking for in the patient, what investigations you can do within that assessment. Um, and also any common surgical problems that might cause problems with ABCD or E ok. So a should we just go around? So we'll start off this side. What sort of things are you looking at? Are they like? Are they? Yeah. So what sort of signs would you um prompt you to think that they have a lot of a airway? They normal do? Yeah. So talking is normally ones are they talking? What might they have if they're not maintaining their airway? Maybe like snoring? Yeah. So snoring. So other other sounds basically. Yeah. OK. Well, im to everyone I can't going on your arm. No, just just shout out things. Ok. So snoring, what else? Episodes? Yeah. Up in the case of episodes, wheezing sounds. Wheezing is a good one. Stridor. Yes. Stridor. Ok. So you all know some good sounds. What sort of interventions? Remember? A to e is not just for assessment, but it's about treating and assessing at the same time simultaneously. So your patient is snoring. Wheezing. They've got upper airway sounds. What can you do to help? Put something inside you can use? Yeah. So that's a good one that we have to forget about. So suction on the, um, you can ask the nurses to connect with the stuff on the wall and you can see, I wanna go sticking your fingers in. If you're not sure what's happening, you can make things worse. Exactly. You don't want to push things in. So someone else mentioned you mentioned. Yeah. So basically, what's the other one? Jaw? What's the other one? Head tilt? Yeah. So those are things that you do immediately at the bedside. You don't need any kit for that. You can do that yourself and you can do that while you're waiting for help. Ok. Um Anything else for airway? Um you can put in one of those. Um so when all of this is not working, the patient is still well, you can use oral tubes. Ok? What else other than this in the same sort of nasopharyngeal? Very good. Ok. And where will you find those things? Excuse my writing um, crush trolley. Exactly. So if you see a patient, you can do all of these things simultaneously. You start assessing, you start doing your head tilt. Um You can ask the nurse to go and get the, so you can ask Alex to go grab the crush trolley. Ok. Um Anything else we're missing, which is not, it's for breathing, but it helps if we give them some supplementary. Ok, we're happy with a, we're gonna start moving to B um which is completely reasonable. So, while you're doing a, you can ask someone else to start oxygen, it's all linked. So, oxygen. Ok. So what are we gonna assess uh saturations? And we've got um we have not you work of breathing? Yeah, if they are or very breathing, use accessory muscles, you can see very good. Um What else is it symmetrical or not? Yeah. So what you're telling me is that you auscultate the? Ok. So you auscultate with your, a lot of the surgical probably don't carry. So how long with you for the auscultation? What else is one of us auscultation? Percussion? Very good. Yeah, especially if there is a, a case of uh test or uh can help. Very good. So you're thinking about the trauma patients. Ok. So these are life in. Yeah. Um how I said you put on. So how can you deliver oxygen? Yeah. So if you're not sure, um, give them 15 L normally breath. Ok. If, um, I know lots of people get bogged down about CO PD and all of those things and you start getting a bit, if they're unwell and they start low, just give them exactly the hypoxia will first. Ok. Um, and then once you're a bit more stable, you can then think about those other things. Given them, you know, varying amounts of oxygen, you can also get nasal specs, you know, if they're not that unwell and the oxygen level is ok? But you want to give them 1 L2 L, you use nasal specs, ok? Often a lot more comfortable for the patient. What if they're not breathing? The B is not stable. What's the next step? Would you do? What if your is not here yet? Yes, you can use a bag valve. So again, that's, that's um available to you on the crash, ok? Just make sure you're familiar with how to grab. So it actually goes in just, you know, a bit of both hand and a lot of pressure, it needs a lot more pressure than you think. And you can do your head tilt and chin lift your first at the same time as you're delivering the oxygen by the, if you're an experience, one, keep the the mask on the patient, the other, someone else do the back because if you are not like experienced an can do it at the same time. But you know, if you're experiencing. Exactly. So and then we said j dementia intubation. So obviously, if um all of those things are failing and your n come, then you know, it may be that they need intubating. All right. Um What are some common respiratory problems that you might see in our ward surgical patients? I'm sure some of you have seen them around aspiration aspiration atelectasis. So that's very common. OK. POSTOP the collapse of the lower airways. What was the one that you said aspiration. Yeah. So, our patients who have small bowel obstruction and large bowel obstruction, they can vomit, they can aspirate, they can get terrible aspiration pneumonia. Ok. What else? Um, so we had a recent patient who had a pe and cystitis who went to ICU. Um, because of the pe, actually they were extremely hypertensive. So they always think about pe, what else? Yeah. POSTOP pop or cup. Ok. Yeah. Yeah. If they come in. Yeah. Um, also uh like allergies and they have uh uh bronchospasm for example. Yeah. So you can think that a lot of our patients get antibiotics or new medications they may get. Um, well, pneumothorax, pneumothorax. Yes. And then your traumatic things. So trauma. So your pneumothorax, your flail chest, um your big hemothorax is pleural effusions. Ok. How might you, so what else is missing from here for people with pneumothorax? Yes. Exactly. So, trachea, remember to look at the trachea? Ok. And uh A is also cervical spine but for trauma patients for we're not specifically talking about trauma today. But um yeah, of course, with trauma, you'll have a little C before A. So you'll know what that sounds for circulation, circulation. So, catastrophic hemorrhage. Ok. So even before a, what's gonna kill them first is if they're actually, if they're hosing out of the body somewhere. Ok. So you have a little c beforehand and also the little C can also be um cervical spine. Yeah. So you're immobilize if they've got tension pneumothorax. What do you do? Um, needle? So, if you can get a chest reading, do it, if not just, uh, do a needle. Um, correct. I think they've changed not in the second or course on how they, it's, now the new guidelines is here. But if, and if you're not comfortable with that, yeah, this is still acceptable. I wanted to get some air out. Exactly. And you're not going to do that much harm really. If you put a, you know, white or cannul in more than that. Yeah, exactly. Um OK. Fine. Let's move on to see. So see. What are we thinking? How are we assessing BP, BP, very good. OK. BP, heart rate. What else? Um Cap cap refills and it's actually very good for perfusion and what might cap refills sort of help you with? Say that your patient's hypertensive, the tachycardic. Um let's say actually their cap refill is really good. It might give you an idea about what the cause of the shock is. You know, if you've got terrible cap refill and you're thinking more hypovolemic. OK. Um What else? Rhythm. Yeah. So you have a feel of the rhythm. OK. Yeah. Well, OK. Um No, it's uh you're not, you're an output. Yeah. So you're an output. One is one that I feel like gets missed sometimes because it's not what you need to think of when you think of cardiac but it's really important. Um, and often it might be a very subtle early sign that something is not right. They're bleeding or um, they're losing volume from somewhere. So what, what should a normal issue out put be? Yeah. So all, all correct. So, naught 0.5 is sort of the lower, lower limit. You want it to be above that. Normally you'd expect it to be like somewhere between 0.5 to 1.5 per mils per kilogram. So remember your, your bigger gentleman who had his appendix C is gonna need more fluid and you're gonna have a different threshold for your tiny pediatric patient. Ok. The, the threshold for kids is different. One quick trick is just get the patient weight, which is on CRS and half it. And this should be the hourly rate like that's a very quick way of doing it in terms of getting people do more with me. II really like looking at your output. So I'm always thinking like, ok, um, if someone has low urine output, let's say they've got a catheter in what's the first step before fluid challenge? Flush the catheter? Exactly. So if they don't have anything else going on, um, and the nurse said, oh, the urine outputs dropped today, I'm a bit worried but they're, they're completely well, new zero. They don't have any other signs often just flushing the catheter and then it will, it will start passing. Ok. So make sure it's not because of that before you start pumping them with fluids and then make the obstruction worse. So bladder scan is really helpful. So, post void residual volumes. Ok. Um OK. What else? So at this point, intervention wise, catheter, catheter is very helpful. Uh Two IV, if you have so IV, access two large more IV. We, we don't do it enough and actually it's something you can kind of forget about when you have a bleeding patient. That's saying you're like, ok, we've got Candida and that's fine. But then you look and it's a tiny blue on this side. So, anesthetists are very good at that. They come and straight away they whack it two gray or two greens. So what happens if you can't get an Can I Yeah, so don't forget you can use IO as well. I don't know why they keep the I OK. In to be honest, I'm sure they have one. I don't know if we have one here. I think people should be trained. I mean, yeah, I think we need to locate where the nearest grab bags are and just put. So remember you've got other options as well. Ok. Um if someone's bleeding, they've got a leg wound that's bleeding out. What do you do it? They do it in tourniquet or stop the bleed. So now it's more preferable to put pressure on first before you use tourniquet because the morbidity is lower. Um ok. Fine. So, I think that's pretty much it. What, what else do we do at this point goes along with IV. Access. Take blood, blood gasses. Yeah. And what else if they don't have the, for the urine output, uh, also catheterized if they don't have a catheter you to monitor. So, if you have a, like acute upper gi bleed they catheterized immediately. It's only the first thing but it should happen. Yeah, it's ECG, that's very important. So, ECG, ok, I think it's pretty much everything. Think about somebody that issue. You think about your group and saves as well. Think about if they're bleeding, I mean, we'll, we'll talk about bleeding a bit more later. But generally you guys know, see pretty well. Ok. And you, you take stuff and to give stuff so you get fluids, antibiotics. Yeah, exactly. So, especially with fluids. Um, the one thing is after you get a fluid challenge, it's a challenge. Right? So, you need to see if they responded to that fluid challenge. You can't just give it and they disappear. You need to hand over to someone or combat yourself. So you give them a fluid challenge. You see if it's improved the heart rate. If not, you can give them a second fluid challenge. How much would you give them, or would you give, let's say, in your average adult, 500 of, and then 500 of sort of eo fluid and they have like 30 MLS per kilogram. But yeah, yeah, I mean, in the emergency situation, it's going to be 500 MS. Um if they've got heart failure or they're very small, tiny, I would give 2 51st and then you can always give them another 250. Ok. And you said that indeed, they resuscitate the patient. Uh or we do like let's be fair and you can see a about running over eight hours. This is not resuscitation fluid, this is a maintenance fluid. So it's a challenge. You need to give it within less than 15 minutes and these guys give hormones. So d what are we going to do? Uh temperature sort of, you know, uh temperature, normal G Yeah, GC. OK. Pills. What can you do if you're not comfortable doing G CSI? Know, I can't do G CS. So, so alert, voice, responsive pain, responsive, unresponsive. That's a very easy way to like quickly check how unwell a patient is. Um what else? BM is really important? And people, we don't forget that anything else. Pupils, yeah, pupils, especially not trauma patients. Um I like to indeed also think about, you can start having a, think about what drugs they've had. So, you know, we have had a few incidences recently of elderly patients with externally overdoses. So thinking about, we had a lady who had a um buscopan reaction um and had a peri arrest. What was it like? Not the name, but yeah. No, No, no, not name. It was before Christmas. It was before Christmas. Yeah. Yeah. She actually had just had Buscopan and then had a peri arrest because she dropped the GCS, which is like a rare side effect of bus, I think, was there was a mistake with her medications. Like they gave, like, no, I think she just never had it before. And then basically she developed a side effect. So I like to ask the nurse when I'm there as well. Has anyone just given something that's new or, you know? So that's a good one. Ok. So e will speed up a few things to do. So it's down here. But you said someone said temperature. Ok. What else? Yeah. So looking everywhere, there might be something obvious that you're missing. So for our patients, a lot of the time it will be examining the surgical wounds, the POSTOP wounds, examining the abdomen, checking for any peritonism, anything obviously leaking or, you know, abdomen, the drains comes in this as well. So, looking at what's coming out of the drains, how much thinking about where the drains are going. Um, and then generally I would think drains in terms of b, if it's a chest drain or c if it's blood. Yeah, of course. If it's a chest drain, then b yeah. Um, otherwise the surgical drains will tend to come in. Ok. So, because this is an order of basically what's going to kill them first. All right. So, don't get distracted by the surgical drain when they've got an airway issue. That's a, yeah, if you get to here and then something goes wrong up here, you have to go back and start in the beginning. I think everyone knows that. So, you keep reassessing. Ok. Good. So everyone knows their A to e very well, what we'll do, I think we start off with a little exercise. So I think the, the her it's panel birthday and I, I'm being very, no. So you're the sho on nights. Ok. Or panels in this case, um, you get six simultaneous phone calls. All right, from various people around the hospital. Your reg is off site at home. I thought we could all talk through together and there's no right answer. I haven't like preset a right answer for this. I just put some scenarios up. We can talk about how you might prioritize these patients. Ok. So you're allowed to ask the, I can be the nurse on the phone. You're allowed to ask the nurse on the phone for extra information. Ok. Um, or the doctor on the phone and then we can make a plan about who you're gonna see first. And you've also got a, you're allowed to ask the nurse to do things, but because you're the S HR night for yourself, you don't have an F one if that makes sense. Ok. So we'll talk about, should we just go through one by one. So the first call you get is I want to refer a 10 year old impedes A&E with abdominal pain and fevers. You need to come now. So the, the A&E doctor is saying, please come right now immediately. Ok. So they're not giving you very good sl handovers. They're just saying come right now. What are you going to ask them what the situation? I'm sure you've had this before. If they, the BP is ok. If they are tachycardic, does it. Yeah. Yeah. Or if you, yeah. Uh, it's good to have a computer in front of you when you're doing that. Uh, ok. So you're not allowed to computer. So you don't have a computer, you have to rely on your, uh, ok. News. And then, uh, some like, are they pre to like, what abdominal pain and fever because it could be, let's say strep throat and, um, so get some actual, so also said news and a bit more information. Um, ok, I'm gonna tell you the patient is tachycardic. He's got a temperature of 38.5. His BP is ok. Holding up. Um, what else are you going to ask her blood? They're not, they've done some blood results on that. Yeah. Ok. What else? How is he himself? Yeah, that's a good question. So, how usually I'll ask the nurse on the phone, are you worried about the patient? So, sometimes I'll be like, No, no, actually he's fine. He's walking around. Um, sometimes I'll be like, no, I'm really worried. Ok. So that gives you an idea of how quickly you need to go. All right. Um, anything else if you think about your sbar? So we sort of know the situation. We know the background. We've got a basic assessment. Yeah. So, have they given anything so far? She said tachycardic and he's got temperature a very good question to get it out of the way if it's not for you age, if it's four years old. Yeah. But we know the age here. So, yeah. Um, 0, 10 years old. What, what can you, you know, what sort of things would it be safe to tell them to give over the phone? Um, we had access, which is a problem in ps get access. So, yeah. So ask them to give some basic things over the phone. If you can, if they can't, then that's fine. Ok. So let's move on to two. So the nurse calls from Asta said as side three, the man with the emergency hearts from yesterday. He's vomiting. Can you prescribe some antibiotics? Ok. Let's, let's get some other, you're contributing a lot. Thank you. But let's, let's get some, get some other opinions you're on c today. Um, I would based on what I have. So this is the first I'm going to see another patient. Yeah. So it's reasonable to say I've got other priorities. Um Is there any more information, would you prescribe this patient straight away ants or would you think about anything else? So, I'll check for any cardiac background. Um Yeah, Q for antiemetics. Um um Have they had antiemetics before? Um um What about the cause of the vomiting? So, are we happy? Are we happy? Just feeling nauseous? Um Anything else you might be worried about? So you said how much procedure? So, or what, what questions can you ask to give you a bit more information to, to see? Yes, you might be able to ask. Is the stoma working? And if the nurse said, oh no, it's quite Dema it's not actually worked since the operation sound like it was quite a difficult hearts. So what else might you be thinking about? Yeah. Ok. And the vomit is, it looks really green doctor. This looks really bilious actually. And he's vomited about 2 L. Are you still going to just go? Ok. Yeah, just give us some cyclizine? All right. Carry on. Thank you. Yeah. So what you might do in the meantime is if you've got a very good nurse like Alex, you can ask him to put an NG in. Ok? If you think it's safe to do so and what could you request or ask someone to request in the meantime? Yeah. So you ask for an xray. So even though it's a POSTOP patient, you have to think about things like eyes or obstruction. Um, and then, yeah, so the point of that one is basically have a little think about what the nurse is asking you. Sometimes they'll, you'll have a patient who's quite unwell and spiking temp. But all they'll ask you is to, um, is for paracetamol. Ok. And then it goes sort of, um, missed while you're busy. Ok. Number three, I want to refer a 60 year old male. I need sis with a perianal abscess, please. What do we think about that one? Mhm. You are very. Exactly. Yes. So if you got six weeks at the same time, you might be like, ok, parent abscess. That's fine. I'll see him later. Send him home for hot clinic. The key word is, yeah. So they're calling from recess and this happens a lot. So always ask always, always whenever they call you for a patient from recess, why are they in recess? Ok. That we didn't have meds and the patient's fine. Ok. Fair enough. But they say, oh no, the patient's spiking 1040. He's got a BP of 80. Yeah. What are you thinking about then? Yeah. So he's clearly very septic. What, what are you worried about? So, medical, some of the medical students, if you've got a patient with a perianal abscess, who's very septic, let's say they're diabetic or they've got lots of health problems. What might you be worried about? Are you compromised? What can spread locally and then become a really nasty thing. Anyone help him out? Yeah, so I always think about neck flash. Never forget. Ok. Um ok, good number four, please. Can you read this 80 year old male with abdominal pain in A&E? Um sorry, we haven't managed to get a CT yet. Uh I know you're busy but his BP is very low, so he's not stable enough to go to the scanner again. What are you going to ask the nurse for? Is it acutely low or is this patient normally hypotensive? Let's start with that. Is he bleeding? Is he bleeding? No bleeding? No bleeding is uh his, yeah, his heart rate is 100 and 20. His BP is 100 systolic. Have you tried? Yeah, we've given him, we've given actually 1 L of fluids in A&E has not helped. Uh doesn't have cat, does he? He hasn't had a CT yet. Um, so can we do a uh uh, yes, we definitely can. Ok. But we don't have somebody like, let's say that we don't have somebody, but that's reasonable. You know, you can ask them to do a Yeah, but well done. The point is that you've, you've got an elderly gentleman with abdo pain. They're telling we haven't got CT. It's very tempting to say, ok, we'll wait for the CT and we'll see him later. But actually they're telling you they're a bit worried because his BP is low. He might not make it to the scanner if we don't see him early. Ok. Number five, I'm calling from recovery. Can you review the Hot Luck Cody from cpod this morning? Um, I've had to empty his drain three times already. Ok. What do you think? What's in the, what's in the drain? Very good question. So, um, yeah, actually it, it looks like blood. It's red. What, what, what's the, like, uh, hemodynamic? Yeah, he's, he's ok. He's, he's quite hypertensive but probably just from the anesthetic. Yes. Ok. What do we think? Can we get an A GG? And then, yes, certainly we can do an ABG. I'll do that. And what are you looking for on the ABG when they come back to you? Yes, exactly. Actually, I II was going to say it takes a bit too. It would still be helpful though. Yeah. Lactate ABG HB. Um, so before you go there you tell them, put the Cannulas have the give fluids. They probably have all of those things because it's a POSTOP and recovery. Yeah. Um, but yeah, exactly. You can ask them to do some basic things. Um, what are you gonna, are you just gonna say, do an ABG? And then what else are you gonna tell the nurse to do after the ABG? Call you back? Yeah. So, always remember to tell them to call you back with the result cos you'll get busy, you'll forget they'll just say, oh, well, the doctor didn't come, so I assumed it was fine. Ok. Uh number six last one, I'm calling from Alex Ward. We just did our drugs round um Mister Brown in 22 suddenly looks very breathless. Ok, what are you going to ask for? What are you going to ask the nurse to do? Is he on oxygen is good? Is his um airway? Is he? Yeah, you probably if you ask him to say Airway patent, you know, that's quite vague. You can, but you can ask for objective things. Yeah. So is he talking to you? Um does he have any swelling? You know, is he objectively what is his saturations? He just said breathless. Have you checked the SS? Does he need any oxygen? If yes, how many liters? Ok. Um fine. So we've had a sort of chat about all six of those. Does anyone want to suggest an order that they would go see these patients in? There's no right answer. 886. Ok. Yeah, I would probably agree to be honest. 645 no 645321. Mhm. 64532. Let's look at on ABC. So six is eight from the looks of it. Um So not just ABC though also, you also have to think about what are some patients? Do they have support somewhere? Yeah. Are they being seen by another doctor if they're they have support? Yeah, if they're on the ward they don't have anyone with us. Exactly. Yeah. So, remember you've got your, you've got your telephone as well. You can also call for help so you can call your registrar in from home. Ok. You can call your registrar in and say, look, I've got six patients. I need to see all of them. Um, who would you ask your registrar to see? Would you think the abdominal? Yeah. If you run me and you told me all of these cases, I probably would go see the guy in Rhesus first. He's probably the most unwell. Um, and then I would go see this abdominal pain from the registrar point of view. You're also thinking like, who is the patient who's going to need surgery first? You know, thinking about surgical planning. If this guy genuinely has neck flash, then he's gonna have to go first. Ok. If this number four, if he's genuinely got a rupture AAA, he also is going to need to go to theater pretty quickly or he's going to need to be stabilized enough to get CT or transfer him out. And five. Yeah, five as well at 3 a.m. Call the consultant and say they say, hey, the drain, the drain is leaking. Ok. Good. All right. I think we can move on. Um, so that's just a little exercise to help you, sort of think about how to deal with things when it gets extremely busy and almost unmanageable, which I'm sure it does most of the time. Ok. Who, who would you be worried about? Apart from three and four? Apart from three and four? Yeah. Um, I would say five, I mean, like, five, I would think if it's blood, if it's blood, if it's bile, something happened. But it's not. Yeah, I agree. If it's b you can get, um, like, yeah, but not like if they're saying they've emptied the drains three times already. Usually we use like the 500 M bags here. That's about 1.5 L. If it genuinely is blood, it may just be a lot of wash. But if genuinely is blood, then that's something I would also try and pop over to recovery pretty quickly to go have a look at. Um, but like you said, in the meantime, you can ask the nurse to check the HB. Um, also you can also ask the anesthetist to help, especially when they're in recovery. Let's say they call you not necessarily about the drain, but let's say the patient's quite, or you can also have to help. So there's always other people to, um, basically assist you send co to six. Yes, that is a very good idea. Also, what else can you do if the nurses said, look, I'm really worried but you're stuck in with the neck flash and they say this guy can't breathe, you know, what do you ask them to do? Exactly. So you tell them straight away, don't even, you know, write anything down your, do you tell them straight away? Put out a 222 call? Ok. And then they will go see that patient. Ok. And I've never seen them getting angry for like calling the parents. They just say, ok, it's fine like you got worried. Yeah, it's definitely the right thing to do. Um, you always can do with more help. Um, and even if everyone comes and patient becomes stable, they they go you haven't lost anything. OK. Good. OK. Well done guys. So we'll we'll do some, we'll do some cases. Ok? Can I say something before that if you get bogged down like you get overwhelmed, just try to come because for me, for example, it can get very overwhelming sometimes if I get all those clips back back, try not to get because also non technical. So try to, you know, detach yourself from the situation, think clearly because yeah, try to isolate from the noise. I mean, it's it and uh not to think with your legs. Yeah, I mean not to run to, I mean focus, you have a team around you, you have uh all your seniors, you have other teams to help you see itu anesthetics. Even if you have two unwell patients, one in the ward and one down there are a lot of doctors there. They can start stabilizing patients with can sepsis sex. So calm down and and can help Yeah, so no, it's OK. I mean everything feels very urgent when they call you, but there's a lot of things that can be done before you get to the patient over the phone. Um and also, you know, as you go along. Ok, so have a paper. Yes, definitely write everything down. So first case is day one post panel, his birthday, he's admitted to ae with epigastric abdominal pain after having a big wiggles caterpillar cake just, just do it. Just let's say you ask him a little bit more and he's had about three bottles of vodka as well. OK. So OK, I don't know if you can see that very clearly. OK. So let's let's come from the the crisp point of view. So you're all crisp people. So what are we going to start with when we assess the panels in? OK. So a a is a pa he's talking too much, he's talking too much. He's definitely, I'm asking for a, so we're gonna look, go to breathing. All right. So what can we see? So his slightly respiratory rate is high 22. His that are OK. But anything concerning? Yeah, he's on 8 L at the moment. So he's 96 but he's on 8 L by um you listen to his chest actually, you don't hear that much. It sounds like he's got pretty good air entry. He doesn't look particularly, you know, like he's struggling to breathe, but he's definitely on 8 L. All right. Yeah. So he doesn't have COPD, but he's a huge chain smoker. So we don't know. Ok. So terrible habit. Terrible, terrible habits. Ok. So what about, um, what can you do for B as well? What else should we check? A AG? Yeah. So you've got a ABG, you, you call your nurse over to also give you a hand because you're going to start taking some bloods and do a lot of things. You call for a bit of help. Um, c what do we think about c um, BP borderline? Sorry, that's high BP borderline. Mhm. Mhm. But um, he's also screaming in pain at the moment as well. So, yeah. Ok. His heart rate is about 1 31 17. Ok. It feels regular. His cap refill is about four when you examine him. All right. He doesn't have any lines. What are you going to do? Yeah, get some blood somewhere else. Two line, two lines, put two lines in. What are you going to give him a, give him a catheter. Definitely want to do it himself. He probably, ok. Yeah, we give him some fluids, right? So I have, we give him a big slog of fluids and then his heart rate comes down to 109, a little bit so a little bit improved BP is still quite high. Um, he's alert. Uh BM is ok. Would you flu this guy? He got t, or would you just give him some, just about eight hours? So, what do you think? Do you think this guy needs resuscitation fluids or maintenance? Well, he's got, he's pack but that could be, he's in pain. So, I think, but if you're thinking it's because he's, what did I tell you about the examination that suggests he probably does need some fluids as well as a, he's got, he's got quite cut refill. He looks a bit shut down. Remember, most of these unwell patients generally will be quite, they may be dehydrated. They may have not been able to eat, they may be vomiting at home. He's probably more likely they're not gonna be um gonna need flu. Ok? But a good thought, you know, sometimes it may not be the hyperemia that's causing the problem. But also if it's, even if it's hypovolemia, it's not until the later stages of shock that the BP drops. So tachycardia is an indication unnecessary. So e his temperature, you can see he's 38.7 39.6. Um, you examine his abdomen, he's got really bad epigastric pain. When you examine him. He's not peritonitic though, but he's definitely very tender. What, what are you going to give him? So you're on your computer next to the bedside, you're seeing the patient. What are you going to prescribe? Give him some paracetamol. Yeah. What else? Just paracetamol, some urine morphine, maybe some or all the good stuff. Exactly. Yeah. Well spotted, well spotted. So, he's got, what is he on his function? He's got an AK that's been quite severe. Yes. He, three of you worried about giving him paracetamol after that, his liver function test? Very good question. Yeah, you might be. Yeah. So, um, maybe we hold off on the paracetamol. Will we give him some? Let's say we give him some oxyCODONE to help the pain? OK. About renal function. Um in terms of so inflammatory markers, what do we think about? We already have the blood back? So we know he's got a we got Yeah, so his lipase is 6000. OK. He has a. So how do we, how do we diagnose pancreatitis? You pretty much got the diagnosis straight away but how do we diagnose pancreatitis? Hm. That's the cause is the cause is pancreatitis but like a lipase three times. Yeah. So there's, there's three things that you can look at. So one of them is lipase is the lipase, the, you know, always gonna be very accurate. Like is it gonna be high every time you check? So the lipase give them. Yeah, it depends on the timing, right? So your lipase peaks and then it comes down. If you've missed that peak, they may not have a very high lipase. It might be only a few 100 you know, it might not be necessarily 6000 like this. What can you do though? For the, we don't do it here though. Not very often. It's a very common. I think the question. So, blood, you don't have lipase. Where can you look for it? Um, urine? No, it's, it's urine, urine, urine, urine. Yeah. Yeah. Sorry. So the point of getting at is you can, you, there's biochemical signs with the lipase level radiological. So the other way to diagnose is if you have a CT that shows inflammation. Uh and then the third thing that you look at is basically um clinical signs. So classic symptom, pancreatitis, epigastric pain, vomiting, um pain that usually radiates to the back with pancreatitis that basically. So out of those three things, bloods, radiology symptoms, you basically two out of three gives you a diagnosis. Ok. Um Fine. Ok. So we've given him fluids, we've given him pain relief. Um Would you give this guy antibiotics? No, no, why not? Um Not like acute pancreatitis doesn't need antibiotics unless it's a necrotizing pancreatitis. Very good. So we just resuscitate analgesia but bilirubin high uh whites are high, bilirubin, whites are not so high. Uh not so high. Yeah, bub I was 100 and 45. So, but there's another thing. No, no, no, let, let, let 40 almost 40. Can you get a temperature of 40 with normal pancreatitis? Good, good. So basically, exactly what you said. So generally it's supportive management. Ok. Unless you're worried that there is a super bacterial infection on top of the panti. So, if the patient's got evidence of necrosis on CT, they're at very high risk of developing infections. They've got, uh, not because they have two bo, of work but because they have a gallstone. Uh, correct. Yeah. Well, let's say they've also got cholecystitis or you strong. Yeah. They, let's say a few weeks ago they had an MRI as an outpatient which showed an obstructing stone and you're worried about is having chondritis. Ok. To be honest, in reality, a lot of patients will end up going on to antibiotics because they come into A&E, they don't really know what's going on. They're septic, they give them antibiotics and I think that's reasonable. You know, um, at what point would you stop those antibiotics? Like, say something came upstairs and they're like, you know, day two treatment, pancreatitis, would you say? Like, oh, we know now that there's not II do tend to do that because, you know, antibiotics do so if they come up. And I think actually there is no indication whatsoever for this patient. Let's say they have an ultrasound. There's no gallstones, alcoholics. They're, they're getting better with the fluids and things I tend to II do tend to stop the antibiotics and look, you can always reassess and we start them if you want to. Um, but let's say they're still quite well, they're still septic. They might need to go to II think it's reasonable to carry them on. It's a risk versus benefit, isn't it? So the risk is that you give, you know, the stewardship side of things, they get side effects from antibiotics or resistance. Yeah. But if the benefit is outweighing that at the moment, then I would still carry on another question. Yeah. So what imaging do you think? So would you, do you ct everyone who has pancreatitis? No, you don't. So why would you, what are the indications to ct someone with pancreatitis? Not sure if you're not sure it's a very good indication. So say they come in and actually say, oh, he's drunk three bottles of vodka. He might have a perforated du All right. It's a bit periton on examination. Um You know, he's, he just doesn't look right and I'm not sure it's completely due to the pancreas then, yeah, 100% CT to rule out other causes. What, what else? Yes, to look for complications of pancreatitis. So say actually we've admitted panels. He's not really getting better. He's now not like managing to eat much and it's day three. I think it's reasonable to do a CT to look for complications of pancreatitis. Ok. So complications wise and we're not gonna go into detail, but um you can think about it in terms of systemic problems and local problems. Ok. So this is very busy, but I've sort of highlighted a couple of things to think about. So local wise, have you got um problems with, let's say peri pancreatic collection necrosis, pseudocyst um systemic wise. Remember, the acute pancreatitis tends to lead to a massive sort of SARS response um which can lead to multiorgan failure and affect lots of other systems, heart respiratory renal um coagulopathy as well. So think about the systemic problems as well. Ok. Um Basically hepatitis is very, it's very varied spectrum disease. Uh You can have people who are very well and you can have people who end up in itu. If you're worried about your patient, let's say you've seen this patient overnight. Who can you call to assess? Yeah. So your reg is not picking up the phone. No med is like, oh, it's gallstone related. I'm not going to see the patient. Yeah. So and as well as ci tu reg as well. So C OT work very closely with the it reg but often it's quite useful to call them directly and they can even give you some advice sometimes over the phone about what you can give the patient. Um Ultimately, if the patient is not getting better with simple things on the ward, like fluids, analges, antibiotics, they might need something more. So they might need inotropes, they might need vasopressors, they might need something a bit more invasive. Ok? And there's not something good to it. You should get. So part of part of um crisp and assessing patients is recognizing when the patient needs to go to a different level of care. Ok. Above the ward level, which is where we all work. All right. Um, if I ever come and I'm off my food because there's no way. I, so thank you panels for letting us discuss your terrible, terrible habits in your entire life. Ok. Case two. I'm interested in time. So we, we'll go over it quicker. So, case two, we've got a 44 year old who's basically had a laparoscopic appendicectomy. It's day five. he had a drain that came out on day two wasn't draining much. He's high BMI, he's diabetic on Metformin. Uh, the nurse has called you because his abs have gone off a little bit and his urine output's dropped to about 10 MS, 10 m an hour, 10 mils an hour. Um, he has got worsening abdominal pain as well. So, this is what you hear over the phone. So, out of that history, I've not given you much information but what is sort of jumping out at you? Yeah. So you're thinking about collection, isn't it? What is it usual for la appendix? Straightforward one to stay in this long. No, no, they were difficult to. Exactly. Exactly. And they had a drain. Right. So, not all of them had a drain. So, already without much info, you can probably gather that it was a terrible appendicectomy. It may have been perforated. Um, they're not the fittest candidate, you know, they're high BMI, they're diabetic as Well, so let's look at the obs his pyrexial, he's got tachycardia of 120. Uh, SAS is 91. He's not on any oxygen at the moment. He's got BM, 12 white cells of 15 C RP of 100 and 10. And it was 54 yesterday. So, what investigations are you going to request? So, let's assume you've done your sort of a, you've given him some oxygen, you some fluids, uh, straightway ultrasound before, before an ultrasound. What would you do first? Yeah. So what sort of things are we going to request at the bedside? Let's see. Culture, culture. That's a good one. Blood culture. We often forget to do that. Um, yeah, urine, urine culture. Yeah. Remembering your sources of infection. POSTOP urine, chest wound has already been removed. But I still had a, you can, exactly, you can see what's coming out the drain if the drains empty. Is that reassuring? Not necessarily. Yeah. So with the world of collect, collect, exactly. If the drain is not going to the right place or it's blocked, it's not going to show you what you need to see. Ok. Um, fine. So we probably would do a chest X ray on this guy. I would say, ok, sats are a little bit low. Um, let's say it's the middle of the night ultrasound. Would you reconsent ultrasound? What would you do? CT? Yeah. So I would probably CT this guy. Um, he's had a significant operation. He's not, well, he's got a high BM. I, um, CT will give you much better information about what you need. Ok. So. Oh, yes. So, what do we also want to have a look at once you've stabilized it? Yes. So, after you stabilize him, you go on to CRS and you have a little look at his note. So, what sort of things? Something out about this? Not, sorry, it's not very big. But, um, yeah. Yeah. So he's got four quadrin fluids. The was the, was used. Yeah, with ac Yes. Correct. So, straight away, you can tell that this was not under straight normal. Ok. So that basically means this patient's high risk of having complications. All right. Um, they've mentioned some bleeding from the appendix artery. I don't know who wrote this up. Actually, I should have left her name. No. No, I don't think it was. I can't remember who it was. Um, so bleeding from the appendix artery again, you might be worried that the patient could be bleeding somewhere. They've used a big washout. So it's 3 L of washout. Ok. So all of these things, even as an F one or a medical student, you can sort of pick up on something that's not quite right. Ok. Let's see if this will play. Ok. So he's had a CT scan overnight, like you said, you spoken to the radiologist. They're happy somehow. They get a contrast. Yeah. So that that big thing in the right. Yeah. What do you think that one? Yeah, no higher higher there. That was a big OK. So you have quite a big collection. It's got some air in. OK. This is a, this is a POSTOP collection. OK? And they can make patients very unwell and sometimes it may not present. So obviously, you know, the patient being tachycardia temperature, it may just be a slow thing, The pain might not be getting better as you'd expect. Um But always think about that. Ok. Um Fine. So how do we manage this patient? Ultimately, we give him antibiotics, done all the basic things. Yeah. So you speak to Ir they say, yeah, we can put a drain in. What if they say? Oh no, actually there's a bit of bowel lying right over the top of the collection. We can't put an ir drain in. What do you do? Yeah. So everything, remember you can do medical management. So antibiotics sometimes that helps alone min minimal lasers. So radiological and you know, uh and then surgical is usually sort of further down the line. Ok. So if they're not getting better, you can't put drain in. Everyone keeps just changing their antibiotics or ultimately, they may need to go back to theater. Ok. Probably the diagnostic. I thought the number which is like case history. Um So you're in A&E no, let's say you're in A&E majors. They fast lead you to A&E recess. Ok. Um, hello, I've got an 80 year old female with pr bleeding and abdominal pain. Um, she was bleeding a bit but now she's past two big bleeds, I think probably about 500 mils each. Um, she's got a past medical history of af she's on a pic span at home. She's got high BP. She's a bit frail performance statements too, but she lives with her daughter at home. Ok. So what are you thinking here? So let's start from the top. So we go to a a patient, let's say you put some oxygen on b what do we think about the I've got some obs there for you. Ok. Yeah. Be uh 9495 to be honest, if they looked a bit unwell and they looked a bit uncomfortable, I probably still would put them on some oxygen. OK? To help. So they may not have very good tissue perfusion. Anything can help to improve oxygen delivery. Ok. Um C so it looks like c might be the problem here, right? So tachycardic and low BP. So they've literally just been wheeled, introduce us. What are you gonna give them fluids? Yeah, so we'll give them a fluid challenge. Ok. Um Yeah, so she's coming with pr bleeding, right? Ideally, you replace life with life in real life. You're not gonna get blood straight away, even with the EG and the major hemorrhage protocol, you're not gonna get um blood straight away. So I would still give them IV fluids and getting, um to help with tissue perfusion, get the BP up. Ok? Uh, you put a catheter in, you do a, some basic bloods that come back. HP ₹78 is ok. 1.24. Um, what are you gonna do next or not? Really? Got good, good, good. Yeah, so cross match some blood. Um, are you going to wait for the cross match blood to come back? She's still hosing at her bottom. Yeah. So I would put out a major hemorrhage for this patient. Um It just means that everyone is on board with what's happening. Sometimes these bleeders can sit in A&E for a while and you know, no one's really noticing that they're getting more unwell. Um sometimes even just activating these protocols, lets everyone know that. Look, this is the one we need to focus on. They're, they're the one that needs attention right now. Um And also you get more people to help. So usually with a major hemorrhage protocol, the anesthetist comes um you have a bit more help to do the logistics of arranging the blood. So in this hospital they, I think they do send a porter down as well to help you with getting the blood from the lab. Um So yeah, OK. So you, you give us two units of transfusion um she's still bleeding. What else could you give her as well? As the T Xa. Ok. Interesting one. So TX A we use in trauma for lower gi bleeding. Um It's actually not been proven to help with outcomes. TX A. So generally for lower gi bleeding is actually not indicated, but if you're not sure and the patients bleeding, you know, I don't think it's unreasonable to how much would you give as well when you prescribe it, what CRS tells you to do is quite a lot. It's usually 1 g, isn't it? Then sometimes it says like like three or like a different amount. As far as I'm aware, it's 1 g IV. And then you can reassess um you can give more than that, but I would start off in your situation when you see the patient yourself. I would just give the 1 g that and then you can. So if you're not sure about questions like that, who can you speak to hematology? Hematology? Yeah. So hematology consultant, part of their on call duties is to deal with patients who are bleeding because they often have to sign off on special blood products. So you can always call the hematologist to give you advice and they're usually really helpful. So what else about her history would prompt you to call the hematologist? I Yeah, so that you may want to consider giving her a reversal and often the hematologist will say, well, it's a clinical decision. Obviously, there's a risk of stroke with reversal, but this patient is actively bleeding that unwell reversed out of that. Ok. Are low. Yeah we do. Yeah, I have I called them several times before as well. Um what other products apart from red cells would you give F FP? Yeah. What else? Platelets? Cryo. Yeah and how what ratio it's still 1 to 1 to 1 to 1 I think as the current guidelines. Um so you're given a ratio of 1 to 1 to 1 because the more you bleed, the more you deplete your clotting factors and that makes the bleeding worse. So you can't just replace the blood. You have to also replace the clotting factors as well. Ok. Good. Um That's a trial that will kill you. Not that trial, it's the in trauma, especially what's the lethal, this is the lethal trial. Hypothermia acidosis. Ok? Um So yeah, general things, major hemorrhage. Um make sure you do all your blood tests that you need, but don't wait for the results to come back if the patient is unwell. Ok. Um, you can start giving transfusions, things like blood glasses will be very helpful because they come back pretty much straight away. Um, communication is important. So I often find in these sort of situations it's a bit unclear as to who's doing what, um, try and delegate clearly you're the person who's gonna go to the lab to get the blood. You're the person who's gonna check the blood with this person. You're the person who's gonna do the catheter. So, really try and make sure that everyone knows what they're doing. Ok? Um, make sure you're doing what you can to restore blood volume. If you're waiting for blood, that means giving fluids. Ok. Even simple things. Like, what can you do at the bedside? Let's say you don't have any want to do a cannula or anything. What's a quick thing you can do to help the BP. So you can, you can do the, um, 10 down the road. So you can raise their legs up. If they're on the ground or in the bed, you can tilt the bed like this. Ok? Um And then, yeah, ultimately, you need to achieve hemostasis. So does the patient need to go to theater? Do they need ir um, what, how are we gonna stop the bleeding? Ok. I'm not gonna go into this. I think George is doing a teaching session next week on lower G bleeding. But basically the current guidelines is generally, if they're stable enough, you want to try and get a CT Angio to look for the site of bleeding before you plan radiological or surgical intervention. Um, and then important things are review their medications. So if you consider a reversal, consider giving them Vitamin K if their inr is raised, um, and then keeping them no by mouth and preparing for the next step of definitive treatment. Ok. Even letting the anesthetist know early that they might need to go to theater is helpful. This is what Panos was saying about classes, um classes of shock. So basically, the thing to note about this chart is that what you can notice that is when they've lost, you know, in the early stages of blood loss, they may not necessarily have any change to their BP, but you're in output. Usually the earliest sign is that their heart rate starts creeping up. So if it's a young patient, they may be like in the 9500, it might not even be flagging up on use. Um, and then once it starts becoming, um, more apparent, then things like the BP will start to drop. So the point is don't be falsely reassured by someone, especially if they're young and fit with a very good BP and good urine output. Ok. Ok. I think this is my last case. So, uh, you've got a patient on the ward ward. He's had an elective open sigmoidectomy. It's day five. he's been a bit slow. You've been seeing him every day on the ward round his bowels haven't opened since the procedure. Uh, he's just still managing only small sips. He's not really eating much. Uh, he's not walking much. He's got a few comorbidities, high BP. B PH type two diabetes, uh, previous laparoscopic appendicectomy. What sort of things do you need to know about this patient? The nurse has called you because he's, she's a bit worried that she's just checked his obs and his heart rate's gone up to 145. So A is patent. Ok. B she's put him on some oxygen. He was looking a bit breathless. Ok. So 4 L, nasal spi that's maintaining it around 96%. Um You listen to his chest, uh he's got a little bit of sort of reduced air entry in the bases. But again, he's after an operation could be as you request a chest X ray, right? So see, heart rate is 100 and 45. What, what are you gonna ask for? CG? Yeah. All right. Yes. Yeah. So the nurse comes with an E CG, you put some fluids up again, you give a fluid bolus check, urine output. So he's still got a catheter in from the operation. Uh They said it's about 30 miles per hour. So it's not too bad actually. You do. Hm. Yeah, lactate is actually 2.5. So a little bit high, you can't explain why. All right. So two, that's his ECG. Ok. What does it show? Mhm. Is it, yeah, in agreement. Afib atrial fibrillation. Ok. The rate is probably about 100 and 30. Um So he's got af all right, and he's not known to have af looking at the history. All right. Um What's going through your mind? Leak? Ok, good. So you've said that straight away. So for the medical students. Um If you have one of these questions about POSTOP patient who's had anastomosis or joint. Ok. Um They suddenly develop af and they're a bit unwell on day four, day five. Always think about a leak. Ok. Especially sometimes they may not necessarily have very severe abdominal pain. The abdomen might be quite soft when you examine. Um but it might be a very sort of subtle sign that something's not quite right. Ok. So you're thinking about a leak? Very good. What are you gonna go and do for this patient? S ok, before CT, so, yeah, let's antibiotics. Ok. All right. Let's have a look. So you go and see you have a look. Uh, it was an elective operation for a cancer. Ok. It seemed to go pretty well. Um, what do we think about this drug chart? So, is there anything that should be stopped? Is there anything that's missing? Yeah. So, yeah. So his BP is low. So we, we stop his, um, anti protectives just for now. Ok. Um, Metformin. Why do we stop Metformin? I like to. Yeah, exactly. So anyone who's septic? Unwell stopped the Metformin? All right. What do we need to do instead? Sorry. Yeah. So if he's unwell and he's diabetic and he's not eating, I think it's very reasonable to put him on an incident sliding scale sometimes. Um, you might get a bit of pushback about that from the nurses and things because it's quite effort to do um for the, to sell the scale and keep doing the EB GS, but it is worth doing if your patient is not. Well, um so remember CRISPR is all about trying to identify potential areas of complication and preventing those happening, basically. Um find anything else on there. What about the Finasteride? What do we think about that? Would you stop that? I'd probably stop that because I think it, it, it can cause a bit of a um BP drop as well. And is it urgent right now? It's not that it's not essential right now. So, on balance, I would stop it. Why? Why is that? Right? It's, it's for uh the patient has 22 PPIs I don't know why the patient has well spotted. Uh So we should probably stop one of those. I keep on the the whole medication. So yeah. So what um what's missing from this chart? Yeah. Would you give this Din straight away? So, before you prescribe Din, yes, I know we're very hot on VT, but this patient is unwell. He might need to have an intervention or he might need to go to the theater. So I would hold off until you have some more information. OK. Because remember the Darin is prophylactic, right? Um Make sure what else is missing pain killers, antibiotics. OK. So broad spectrum antibiotics, we start those that's pretty much it. Um Obviously fluids will be on the bottom of the chart. Ok, good. So we've seen the E CG. Let's look at the CT quickly. I promise we're almost done. Guys pretend that this guy doesn't have a ST I didn't mention that before. Ok. What do you think? I can replay a little bit. Yeah, he's got a leak, hasn't he? So he's far down. You can see this sort of say Presacral collection here. Ok. There's some air in there, there's some fluid. Um, it's clear and often when you get like, leaks quite low down like this, you can imagine if you're examining the abdomen, you may not even find any signs necessarily. They may not be guarding as much as you think. Um, any patient that's not progressing after surgery or they've got subtle signs like new af or the inflammatory markers are creeping up a bit. But they're saying, oh, no, I actually feel quite well. I opened my bowels yesterday. Um, basically have a lower threshold to scan them and, or, or discuss with your senior about scanning them. Ok. And ask them if they have pelvic pain. Sometimes they have this pelvic pain and not abdominal pain. Exactly. I think is obese this patient, let's say a little bit on the side. Also, with obese patients, they lack of abdominal pain, doesn't mean anything that can be perit and reading the paper. Uh, uh, obesity can mask the abdominal pain a lot. So, always. So again, this patient, this patient ended up so much later. All right. So the didn't look very drain and below. So it was quite low down. So overall key points. So from your side of things, you know, everyone can do basic things to help. So systematic assessment, you can, everyone can do an A to E there's got plenty of things on there that can be done to help stabilize the patient. Um Always think about intervention as you're assessing as well. Um Like panel said, you can give oxygen while you're assessing airway, you can ask your nurse to help take some bloods or do an ECG while you're doing other things. Ok? Um Always make sure that you check that whatever you've done has been effective. So often there's a problem with doing something and then disappearing because you're busy to do something else and then the nurse may not remember to call you back. So always go back and check or ask someone else to go back and check or call you back about whether the fluids have made the heart rate better. Ok. Communication is important. And then um basically the the sort of catch phrase for the crisp course is that prompt, simple actions, save lives and prevent complications. So it's all about doing simple um and quick bedside things to prevent the patient ended up ending up in ICU or ending up with kidney failure. So all of these things at the early stage can really help it's not just about the operation itself that saves the patient. Ok, good. Well done. Well done everyone. Any questions about anything? Oh, II forget about the online people. Any questions, questions at home. Um A yes, the recording will be available. Sorry for not. I said um laughing emoji, laughing emoji. I look for obstructions early head. Yes. Well done guys. Ok. Thank you. And thanks Panos for sponsoring this talk with you, sir. So 1010 10, come and go. Thank guys for attending.