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Okay, good evening everyone. Thank you to those who have just joined us. So this is uh the second talk in our series on mrcs revision. For those of you who weren't here last week, essentially, this is a series that's running every Wednesday covering different aspects of the mrcs exam. Um And tonight, we have the lovely Lily who is currently a corps trainee on Tino in Cardiff. So she is best placed to present to us tonight. Talk on 80 less and shock with the Mrcs on in mind. So, um without further ado do I will hand over to Lily. Uh Thank you so much. So I'm going to try and do it in a sort of question based format because I think that's obviously the most relevant going through for the mrcs part A but 80 Ls and shock is something that's the whole way through both part A and part B. So I did my part A in 2019 and I just passed my part B earlier this year and it's a favorite topic to come up and it's quite a good one because A TLS is one of the other things that we have to have as part of the sort of course surgical training curriculum. Um, and the earlier you can go on A T L s, I think the better because it's a really, really good course, it's actually really relevant for work. Um, and for anyone that works in the heath that you go to so many trauma cols you get, the more, the more that, you know, the more you get out of it. So if you know you're 80 less principles really well, um then you get a lot out of your trauma cause you get to do a bit more. So just loading their, I went back through the curriculum and sort of pulled out the parts in which 80 Ls and shock questions can come up throughout the curriculum. So we can have applied surgical physiology, which is um, no one's favorite bit definitely, but it certainly comes up within that, that sort of section, applied surgical pathology again. So those questions can be sort of the general principles of a tlso. They can be more sort of organ or system specific. And then within the assessment and management of patient's with trauma is a whole curriculum heading. So there's loads of places that they can sort of pepper pot these 80. Yes and shock questions in. So it's a topic that's, I think quite straightforward to learn because it's something that we see every day. So if you know the principles well, then you can easily do well in those questions and you'll see them in both paper, one and paper to so the morning and the afternoon and then when you do your part B they'll almost certainly be a question on either trauma or shock in there. So broadly speaking again, we can sort of divide the questions that you'll be asked on 80 less or shock into questions relating to the primary survey. And the primary survey is like the the big thing in the 80 less algorithm because it's where you get mostly information and it's slightly different to sort of the other teachings of A L S and some of the other sort of immediate management in that 80 LS is procedure based resuscitation throughout the sort of primary survey. So um for anyone that's obviously been on the trauma calls and stuff in the heath, they'll say, right, you're the procedure doctor, you're the this doctor and you kind of do a lot more during that initial assessment than perhaps the sort of classic LSAT assessment. Um or you can have questions which are kind of organ specific or case specific questions relating to a patient who's had a trauma or who is a, you know, 80 less patient or a patient that's in shock. So sort of organ specific in case specific questions you'll often find as you're revising through the other topics. So like when you're doing some cardio classics, you might see some bits on trauma there or when you're doing the general surgery might find some bits of pieces on trauma there and, you know, everyone has a slightly different way of revising for the mrcs. But I found that dividing them up into specialties was the easiest way for me to kind of like chunk it and realized, like, okay, that seems a bit more manageable rather than looking at the curriculum as a whole. And I did the same for both parts where I kind of thought, right? This is a general surgical day and on some of the platforms, you can like divide up to just answer general surgical questions and A T L s is all the way through general surgery. They look after lots of the trauma patient. So, um yeah, it's kind of within that subspecialty and then obviously trauma phoenix as well as kind of throw sticks and the other outline specialty. So general um A TLS principles all start with the primary survey and I've put the C in brackets there because it's something that is kind of like a bit of a bone of contentions. Some people will include the, see, um see which is predominantly control of catastrophic hemorrhage, but some people mentioned c spine as well. Um And I think that it's important just in general to think about understanding like the approach to a patient with trauma, knowing that we should be controlling the C spine. But actually a is still the most important in terms of, of your initial primary survey and the control of catastrophic hemorrhage is kind of a bit more military medicine and it's not necessarily what we see on a day to day basis occasionally. Yes. And we will see patient's who have a primary see problem, but it is very, I've never seen anyone come through the front door of the heath with, you know, a catastrophic hemorrhage that is more pressing than assessing their a to ease. Because that is kind of like when you're thinking like blast or gunshot or extremity blown off where they are fully, fully hemorrhaging, which we don't see much of thankfully. Um So, like I said earlier, I think 80 less is a great course to do. Um As soon as you can just because it's actually quite fun. Um It's expensive as all of the Royal college courses are. But I think it's the one that I probably use the principles of most often within sort of day to day. And there's always something different, you know, every trauma call slightly different. And it's a really simple algorithm that you can follow basically every time you see a trauma patient. And as the more junior members of the trauma team, which we always are essentially, you will often just be told, right? You're doing primary survey. So the more you can do with the. So my cat is climbing the window, the more primary surveys you can do the easier this comes. So you, you've got the knowledge then based for your part A and then you have your sort of ready to present for your part. B and you know, that it's sort of going, you know, going in and actually your understanding the principles rather than just kind of regurgitating them. So we'll go through the, I'm going to do A two D because I don't think there's too many questions in E um, and sort of just pick out some of the main core principles of the, of the procedures and sort of questions that could be asked, um, in each topic and then we'll go through a couple of questions, um, which are sort of related to the, the, you know, topic in hand. So, um, airway is obviously the first thing we do, we need to do a rapid assessment of the airway and we need to consider airway trauma with airway, sort of patience when they come in, in, in real life. Um, they haven't any cyst that comes and helps you or you have the nieces that comes and helps you. And that's excellent because that songs your fear of the airway, the 80 less, um, day or whatever, the course you go on. I went on E M S T, which is the new Zealand version. And they'll tell you as you're going through like, no, you're the only doctor. There's no honest this around you have to handle the airway So for the exam, it is worth learning some of the simple airway adjunct. And then the big thing that I think I sort of saw throughout all of my revision for both the A and the B is this um emphasis on the definitive airway as a definition and the G C s of eight because it comes up time and time again. And actually, I don't think it's very often a decision that we make in real terms because patient's either come in with a definitive airway or it's clear that they're going to need a definitive airway because there's kind of write down 34 or they're fine. I've never been in a situation where I've been like, okay, this patient suddenly gone from a nine to and eight and now we need to think about an airway, but somehow in the HLS um scenarios, they always will just tip over to that. It's just gone below eight. Um And for the purpose of any exam question, um, it's like a viable question. You talk about maintaining cervical spine alignment, but your airway is still, it's what's going to get you first. So your airways most important trumps everything else. And like I said, we're really glad we have any tests because they are handling that for us. So, um I don't know if the little effects will work on my PDF now, but I've got a couple of questions based on the A um section which you can just do on your own. Um, and then we'll talk through them and I'll try and like, pick out some of the general themes that keep coming up in, um, the jet, like the multiple choice questions and something someone said to me, which is a bit disheartening was that the exams are hard because they want money from you, which I don't necessarily think is the best way to look at it. But sometimes there are incidences where the questions are trying to catch you out and it's not particularly nice and it's not particularly fair, but the more questions you do, which I think is the best way to revise for your part. A the more equipped you are for um answering those sort of questions if they come up. So first thing to say with sort of a question like this is just reading the words and having these negative questions in there can be really frustrating because in a rush, it would be really easy to read this as which of the following is a definitive airway and you think right, I'll just circle which one I think for, I'll enter on the system, which one I think is the definitive airway and move on. Whereas if you read the question twice every time you can see that actually, it's the opposite kind of question here. They're asking what isn't a definitive airway. Um So I'll see if my effects work. No, I had lovely effects on the, on the slides. Um So the question answer for this one would be see. So C is not a definitive airway because it's a good L tube. It's a, it's a sort of um it's just in the upper airway and like I said briefly earlier, that's the definition that just seems to come up time and time again. What is the definition of a definitive airway? Think it came up with my CST interview. It came up at my mrcs part B. I'm sure those for your question about it somewhere in part A. So just remembering that it's a cuff to below the level of the vocal chords with the cuff inflated and you have to have all of those kind of bits. So yeah, it could be a track, it could be an empty or an E T tube. And if you had rushed through that question, you might not have got what is actually quite a straightforward question. Um I did my exam on paper back in when I did it was in one of the hotels in Cardiff and it was quite nice because I could like circle the exam paper and things like that. Um And I find that quite a good way to kind of get the keywords into my brain is circle highlight, pick out what those key bits of the the question are. So it's a bit harder to do that online and, you know, frequently were going more and more to online exams because they're much easier for people to mark, they're much more robust for people to mark. Um, but with that in mind, you really have to read the question a couple of times then because it's probably more easy to kind of rush through a written question. And if you get a bit of screen fatigue when you're staring at a screen and you're kind of, you know, going through what's really, really stressful exam, um It can be tough to kind of pick out that. So I hope that made sense, that question to everyone. And that was sort of my first point on airway definitive airway comes up all the time and remember to read the question properly. So that if it is a negative question, you answer the right question, next question. Um So it's still an airway question which will probably give away the answer a little bit there, but it could disguise itself as a sort of D or disability question or, you know, even a secular trauma individual system question. And again, it would be quite like easy if you're rushing to think head injury. Okay. Well, do I, I need a CT, there's bleeding. Should I suture the scalp? I need to know whether there's any neurology because all of that is really, really, really important. But that's secondary survey stuff. It's just going back to the principles of the A T L S algorithm which is always a trumps everything unless your patient's bleeding out in front of you, which they very rarely are. So it's always a first, always secure the airway. So that means that B is the right answer for this question. And I'd be more than happy I can send these slides out afterwards because I know that at this point in revision, any extra question is always great. So um I will, I will happily share those. Um Generally speaking, I think that some parts of the mrcs is quite like an intuitive thing to learn, like stuff you learn from work stuff that you kind of just have to build on. And some of it will require like a little bit of rote learning. And the definitions is that kind of one where is this question is something that you can sit for a moment and, and try and work out um and get to the correct answer. I'm sure you would um just on this bit, I'll touch again on that gcs of eight. So a head injury in this kind of, of scenarios is listed as quite vague. Um This, you know, a head injury and this patient could be a bump on the head, it could be uh an intubated patient or a comatose patient. Um So always just having in the back of your mind that gcs of eight and whenever we were revising again for the part B, um some of the questions in the question banks were finding have that sort of period home home that never happens in real life where the patient just suddenly goes to GCS at seven. So just always think airway, airway, airway reassess, etcetera. Okay. That's our way we're going to be for breathing, which is a hugely broad topic in terms of, um, the potential injuries that can come from a trauma patient. Whenever I'm doing a primary survey, it's always a bit that kind of scares me the most because it's so loud in there. And you've got your stethoscope, which normally isn't your stethoscope because you've left it upstairs. So you got one of those really rubbish e plasticky stethoscopes and you're listening to this chest thinking, all I can hear is noise around me. Um So in the exam sort of mrcs a questions, it's just really picking out what exam findings they've given you again in, in sort of my experience of, of trauma as it comes through the front door. The be problem is either identified at the scene. It's a massive pneumothorax, massive hemothorax and something's been done. So, for example, Thoracostomy zack needle decompression, even like tubes at the scene. Now, the Emirates team are amazing. They do some in credible stuff on the side of the road or the side of the mountain, whatever. Um, or it's something that's kind of picked up in the scan, er, and they'll say small pneumothorax and you think, oh, well, I didn't pick up that they were reduced. Breath sounds, but no one really minds. So when you're assessing it's look, feel move with anything. So looking at the chest rising for, looking for seatbelt marks, looking for bruising, looking for an obvious flail chest again. I've never seen one. I'm sure it was great to see. I've seen patient's with like radiological flail chest, but they've never had that nice in out breathing. Um So maybe I need to spend more time down in any at the trauma calls. But the favorite question around the mrcs is about chess training session and it's kind of an area of the trauma assessment that is quick and easily done. Everyone says, like get chest training, we'll do that. Now, it's assessed in part B exam as a practical skill. It's assessed in the A T L S assessment as a practical skill. Um And it is something that in lots of trust will actually fall to general surgery or like the and the lot because cardiothoracic six are very rarely act the tropicals and are quite fun and quite satisfied. But chest training, you get a big gush of blood and you feel great about it because you are obviously got it in the right place. Um So the chest strain kind of extrapolates out into loads of questions because there's things you can ask about landmarks. There's things you can ask about definitions of massive hemothorax problems with chest strains underwater seals. And when I said that some pit bits of mrcs are like quite nice to learn and some bits just require learning bits about the chest rain. I think just require learning. Um One of the questions you can have is about the layers that you pass as you're going into chest room, which is in my view, quite irrelevant knowledge because as long as you go through the pleura and you're in the right space at the end, like, do I need to know, you know what I'm encountering all along the way? But I can see the logic and about the the landmark or the safe triangle um for chest rain insertion and that changes every now and again, a TLS update their guidelines. So that can sometimes take a little while to filter down and to into the exam is probably the last thing to catch up worryingly. But certainly question banks. Sometimes we'll have information that is actually not entirely up to date. So for example, the general idea for a needle decompression, we used to think upper, we used to say second space. Um Lots of cattle eric studies recently have shown that that often misses a pneumothorax. So the the ideal treatment for a side of the road tension now is a finger thoracostomy. So that guidance was even in like the, the MRCS courses, I just did. We talked about it and they were kind of like, oh, we're not sure if that's made that into the exam yet. So do whatever is, um, coming up regularly in your sort of past questions. And if you have sound knowledge of the 80 less guidance, obviously go with that and be reassured that if a question is not done right by enough people, it won't part, like go through and pass through the marks. Question's always get pulled out of these exams because it's really hard to write new questions. It's really hard to write M C Q s. So if a new one gets written and then, you know, there wasn't consensus in the candidates of getting the right answer, then they'll probably pull the question and reword it. So obviously work as hard as you can to get to the right answer. But if you are looking at a question, you think, right, I've read that that guideline has changed recently and it's unclear if the right answer is in there, just answer what you think is best move on and be reassured that not all questions make it through and the exam can be slow getting those new sort of changes. So, yeah, best guidance is to learn the hdls Guidance because that's what you need to know. But obviously just don't be disheartened if you're doing past med questions and that isn't quite matching up because it takes ages for all of these questions to get filtered. I've written some questions for like the medical students before and there was like three stages of approval for a question to get through. It was really quite simple. Um *** said, didn't do it for too much longer cause it was just too much hassle. But yeah, just sort of had that in the back of your mind. So we'll do a couple of questions on breathing. Um Go through these sort of again just as we did with the last one. So have a read, Have a think and then I'll sort of talk about the rationale of the answer and um, other principals I think it's worth knowing for the exam. So this one's quite a long stem, there's lots to read which they're often can be um, in the exams and it can feel like there's not that much time to do. So it's just important to kind of try and take as much of that good information away as you can. So, um, long and short of it is you've got a trauma patient and you put a chest training or a chest tube. This is an American question that I borrowed. Um, so it's a lot of words, but actually for quite a simple question. And when I went back right at the beginning and said, there's these two types of questions to me, this is a primary survey question rather than a sort of system specific or um, see or be question because there's a lot about breathing. There's a lot about chest trains. But actually the question is what do you do in a primary survey? Which is a, I hope that everyone agrees with that. It's, it's re examine its go back and reassess. Whole principle of a TLS is assess act reassess, keep reassessing real, assess your patient because if you put your chest drain in and then you go on to, you know, your next step and you haven't realized that your chest trains, not bubbling, not swinging your chest sounds, don't sound better. Whatever. It's no good putting that chest training cause you ain't done thing useful. You just put a tube in somewhere and you're not sure what it's doing. So in theory and in practice, you always re examine the chest and you definitely do and when you're, you know, putting a chest rain and I find like it's still quite a nervous thing to do. Like put a tube into someone's lung and you feel like, well, I shouldn't be going in there and like kind of anxious about it. So you have a good listen before. You know what it sounds like it's normal. A little bit quieter by the time the decisions you know, be made that you need a chest drain. Um The primary survey will still be going on around you but you will, you know you've got your procedure now, your, the procedures doctor you put in the drain in, you've got time to kind of like think right? I know what I'm doing and I know what I have to do afterwards is immediately reassess the patient. And the only option here that involves reassessing the patient is to re examine the chest. Um, generally speaking, actually, after you put in a chest drain, yes, you're re examining the chest, but you're re examining all the patient's observations. You're looking at the drain, you're looking at the patient's numbers, you're looking at their oxygen sats their oxygen requirement. But sometimes the best answer isn't in these single best answer questions. You think they're all rubbish? I wouldn't do any of these. So you have to find one that makes sense and just go with it. And if none of them make sense, there's really, really nothing to be gained from sitting and stressing over one question when you've got to exams worth of questions to go through. Um, and it's a big exam. It's a long exam. It's a long day and it's miserable, but it'll be fantastic when you passed. And, you know, it's, it's definitely, um, an exam that is, it's doable if you just do the questions and, and sort of learn the principles. So that's that one. And we'll do another question on breathing. Um, which is similar a little bit of a story beforehand, something to read, which is more relevant. I'd say to the question in this one. So it's a young woman. Um, again, sorry, these are American questions, you know, she was in an automobile accident. Um She's short breath, respirators, 60 breaths a minute in credible. Um And she's got markedly diminished breath sounds on the right side. Um Chest X ray would probably reveal and this is where I've kind of maybe, maybe I'm harboring some resentment from the questions in the mrcs part. A sometimes they will put answers in there that I just think are there to try and catch you out where the, you know, the it sounds right, but something's not 100%. So a if we say shifting trick ear towards the right, you think like the trachea shifted and it would be easy to focus on that bit of the answer. But actually, if you think about what you're worried about, which is attention pneumothorax or a massive hemothorax. But someone this so well with sort of 60 breaths a minute who's really not, not doing so bright, you think probably tension ing rather than than hemothorax? And it's obviously going to be pushing the other way. Um hyperinflation of the left lung is kind of not really relevant. We're worried about the right, the right lung and then consolidation of the right lung like yeah, you could have reduced breath sounds with consolidation. But does it make sense within the scenario? So the correct answer for this question was air in the right pleural space, which seems like a weird way of describing the pathology of attention. But actually, it's kind of where all of these questions come together because it is boring to just ask pathology questions and physiology questions. So they try and make it feel a bit more exciting by putting a scenario with it. But actually, that's a question that do you understand the physiology and pathology of tension ng um which is sort of air in that space. And that's why you put the drain in, drain that space, put it in underwater, see or stop drain a re entering and you're out of trouble and everyone's happy. And then you X ray obviously after your um chest drains gone in, after usually assess the patient. So the guidelines again, as I mentioned, change for everything all the time and the guidelines for the safe triangle or safe space have recently updated as well. Um In the in this diagram, it does show the line coming backwards from the nipple and new way to less guidance is recommended not using that landmark because it is so inconsistent. So they've labeled it correctly as the fifth intercostal space, which is what you should be counting. Um Less so for part A but more for part B when you do any examination where you have a landmark, you gotta be really theatrical with it. Like you're driving test mirror signal maneuver, like you count every rib. When actually in reality, it's more obvious in a person who's actually unwell, like you just lift their arm up, you look for the landmarks, you will sort of look back from where the line of the nipple is and think up here is safe. You don't have to have it, you know, dead perfect in the exact landmark that they've asked because that's why it's a triangle of safety rather than a, a surgical landmark. It's slightly different to us thinking about, you know, the landmarks by laproscopy ports or something because, you know, we've got a bit more time with that so we can work out are landmarks. This is a, a triangle or an area that is safe and that's why we just need to again learn off those boundaries. But if you think of it in your sort of own arm here, look at your own armpit in the mirror movie. Um It's quite clear with the way that Peck Major Latte and Dorsey sort of make that bridge up into the Axler and it's just, it is a lovely safe triangle where you can do not much wrong by putting something sharp in there, but just obviously uh doing it appropriately and following the guidelines. So the terrible chest X ray from one of the hospitals recently where the chest train was all the way through and nearly out the other side. I don't know what happened there. Um So definitely try and avoid that. And in your procedural based stations for your part B it's all about just yes, showing that, you know what you're doing because the dummy or the mannequin will never work the way you want it to. Um, for my exam. I had a catheter that definitely was never going to go in the model. And the guy was like, yeah, it doesn't really work and I was, like, excellent. So there's not often much in the way of expenses fed in these exams. So, um, then what you should do is say what you would do and don't be disheartened if in, when you're coming up to your part, b if it's not, doesn't go as smoothly. Um And in your part, a just remember that it's kind of definitions based and it's all based on the guidelines that were correct at the time of developing the exam. So it may not be the exact guidance that you've read flying through. So we'll cover, see. And I think that circulation is where the majority of these kind of shock definition questions will come in. Um And the reason for that is because a TLS shock is, it's always hypovolemic and it's always hemorrhagic until proven otherwise, you're, you treat 80 less like the patient is bleeding. And then if you find that actually, you know, they crashed their car because they had an anaphylactic reaction to a bee that just stung them, that is niche and less likely to happen than a bleed in a trauma patient. So, um general principles of assessing for circulation, um pulses, numbers, whatever they'll be up on your screen patient will be monitored from the moment they're transferred from the emails or the amber bed onto your bed. You've got a pulse, you've got a BP, you're feeling the patient as a trauma orthopedic themed doctor. Our sort of thing that we go and do as we feel the thighs. We say, you know, this, you know, the thighs and ice and soft, not worried about bleeding into the thigh. We have a little rock on the pelvis. We comment on the pelvic binder and we're always thinking about that blood on the floor for more the places that you can lose blood into. So chest abdomen, pelvis and long bones and actually, um the silver trauma calls that we get, we really uh I think could be hotter on recognizing that these little long ladies with their, you know, non displaced pelvic fractures from low energy fall, often have these huge hemotomas posteriorly and we worry about blood clots who put them on Kleck saying their kidneys aren't as good as they should be. So we've given them high dose anti coagulant and then they drop their uh their hemoglobin the next day. So there is loads of places in the in the body, the blood can hide without causing too much of a, a sort of obvious show at the original point of presentation, um knowledge of blood products and transfusion guidelines. Um That's one of those kind of, you just have to learn it, things you'll know when you're on the wards or whatever, when you're transfusing patient's and when you're, you know what the guidelines are in terms of giving additional medications, irradiated blood grouping. I think blood group questions are probably fair game if I remember correctly. Um, and it's the kind of thing that will take 20 minutes, 30 minutes to learn and commit to memory, but it's worth doing it because these exams can be so tight in that like every, every mark counts. And if you can add a little something, um sort of layering new revision where if you're, you know, thinking about 80 Ls and shock and bleeding and you think, okay, why don't I just learn blood groups again because I used to know it. So I'll just add it on to this. So consideration of all the possible circulatory traumas, um blood in the abdomen and the chest seem to be the ones that kind of present in a an exam setting. Um And this may have been a sort of question on past med. It might have been on one of the other settings where there's a specific question on how much blood can be lost into the femur. And I believe the answer is at 1.5 liters and I don't know, you know how validated that is, but it was in amongst some answers that were kind of just didn't seem right. There was one that was like six liters I was on and that doesn't seem right. And there's one that was like 200 mils. So sometimes you might not think I know the exact answer to that, but a little bit of some sort of guess what, by just deducing out the right the question answers that don't seem right can be the best way to ship. So, um all, all exam patient's are 70 kg 17 70 kg then because that's what all physiology is based on. So it, the questions will normally put that caveat on. There will be questions about pregnant women and they have their own set of terrifying physiology and that the obstetricians and gynecologists are happy with most other people will be terrified if they see a pregnant person coming into a trauma call. Um And that's worth reading in the 80 less guidance. You can actually download the HDLs book online for free. Um If you just search HLS PDF, it'll probably be one version behind, but it's a good read. Um So this question, 70 kg man suffers an estimated blood loss of two liters. He's got two liters of blood on the floor, the cleaners mopping it up, which of the following statements will apply. So it's not really a clinical question. Other, it's a question about having to know the horrible table that I put up on the next slide. Um So questions on pulse pressure, urine output tachycardias and then the other things in this table would be your confusion, mental status and respiratory rate. So um going through those, I got the, the answer to be d so two liters is a lot of blood loss. Um and it narrows the pulse pressure because he's crashed everything at this point. So we'll look at the table. Now, this is um a favorite of exam questions, interview questions, the A questions and in general, um it's something that I think can be hard to remember all of the bits and pieces about it. But if you kind of get the right sort of pattern of it, it feels a bit easier. So I don't watch or play tennis. So correct me. This is wrong. But someone once told me it's like a tennis match. 15, 30 30 40 40 love, maybe I'm incorrect there. But it's a good way of remembering it for me because blood loss is kind of the bit that changes here. So percentage of blood loss and then everything else kind of follows a pattern. But it was something that I came into the exam and I knew that I maybe only just managed to commit this whole table to memory and I scribbled it down on the piece of paper that we were given for notes because I had to have like that down in front of me and it definitely came up on at least two or three questions, different picky bits of this table. Um So unfortunately, something that I think you have to just learn and know and we'll always come up and in sort of reality, what we're really looking at is we're looking at the, the whole, the BP, the pulse and the patient's mental status is what we actually look at acutely. So if someone comes in handed out from the ambulance, tachycardic, they've tanked their BP and they're confused. I don't really, you know, I'm not thinking all this patient's lost over, you know, 2000 miles or their respiratory rate should be this or their urine up. But I think this patient is hemorrhaging, they are sick and that's kind of what it actually is in real life is quick recognition of severe pathology. But in the exam, you got to know. So you just got to learn it. Um And then this question you can tell I probably wrote it because it's so simple in that. It's uh an actual patient. I looked after my year out where a lovely lady was brought in, kicked by a horse hypertensive tachycardic. And I worked in a neural center um where resources were wee bit limited. So decision was made after fast scan um to take this patient straight to theater. And at laparotomy, the consultant showed me this horrible looking what should have been a spleen and said, what grade is this injury? And I was thinking bad, it's definitely bad, so shattered spleen. Um Everyone I hope agrees is five and those are the sort of to grading systems I would bother to learn for the mrcs is your splenic injury and then your renal injury. Generally speaking, one is okay. Five is really bad. Earlier stages we can manage conservatively. Um in years gone by, used to take a lot of spins out. Now, we don't take as many spins out and the middle bit now can be beautifully looked after by the interventional radiologists. And that's something that again, guidelines are changing. And you may not need necessarily see that always reflected in the questions that you're answering. So just answer it in the most sensible way you can and be reassured that if the question doesn't make, you know, if you feel like the question doesn't match the guidelines, then they will probably pick that up at some point. So that spleen this is kidney, basically the same shattered really bad. Can't save it. Um Take it out because it being in there is more detriment because it's bleeding and it's a source of blood loss. Um If it's fine, leave it alone. If it's somewhere in the middle, speak to I R speak to someone else. But that is that gray area. So it would be unlikely um for you to get a question asking about the management of a patient in the gray area, but it would be completely reasonable. And within the realms of mrcs to ask the, you know, give you a definition of what, you know, type of injury is, is there um and ask you to grade it and that's the American Association of Trauma Surgeons. Grade ing's. Um, they grade all, you know, hollow or solid organs into some kind of grading system that spin and kidney are the ones that seem to come up more recurrently and spain in particular is something that's um good to know about. It's really interesting trauma. Um And there's obviously some more questions that can follow on from splenic trauma because there's all of the antibiotics, the vaccines, and it's not a fun thing to learn, but it's one of those things you just got to learn what vaccines do they need. Um What antibiotics do they need? The guidelines are different depending on the age of the patient. Are they under 16/16? And in general, they're quite um frustrate to look after sort of in the immediate thing because the guidelines are quite variable depending on whether they have or haven't had certain vaccines ideologies changing whether we should be doing it. But for the sake of the exam, learn, the guidelines are probably nice guidelines on what vaccinations are needed for splenectomy. And that covers elective splenectomy as well, which is less common again, but make them up. We're nearly there. I promise. Um Disability is nearing the end obviously of the primary survey. And I think that the questions that are most regularly aren't asked the dcs questions because it's easy to write a question on G C S. Um, and it's something that you, again, you've just got to know and nice trauma centers just have a nice G C s but like sign on the wall so you can do the G C S really quickly. I don't know. Yeah, I'm sure people are quicker slicker neurosurgeons where we can work that gcs out just, you know, by looking at the end of the bed, I need to actually think right. I'm taking one off of this one off of that and, and I hate being asked immediately, G C S questions was really dreading it in my part. B and I remembered back this sort of teaching method that someone talk about G C S, which I'll go through in a second, which is one of these silly little things that I've probably been doing for like the last five plus years of how to remember gcs and probably would make sense to anyone else, but it works for me. So we'll go through that. The other thing is the shock table that we've just been through. So a patient that is confused, yes, may have a head injury causing their disability. But are they confused because they're in shock? Are they confused because they've been hit in the head? Are they confused because their blood sugars are low? There's kind of all these little extra bits um within that assessment that when you do an actual assessment of someone's, uh you know, primary survey that you will think about. But in the exam will be the kind of thing that are there, you know, to make sure that you're thinking broadly. Um And the exam itself is, is to make sure that you're safe and able to work at the level of like a registrar, you have to pass it by the end of your core training. Um So it's, it's all stuff that's, you know, meant to be useful to know, although some of it, I'm sure it just feels really frustrating. So, um this is more of an anatomy question. I'll let you have a quick read of the sort of stem there. And it's a question, I think that is really, really common. Um It's commonly asked about the sort of anatomy of um intracranial pathology. And it's one of those kind of two step questions because to get to the answer you have to know the diagnosis, but the diagnosis isn't given to you in the, in the stem of the question. So, um I got this one as the middle meningeal artery. And that's because the question is alluding to the fact that the patient has had an extradural hemorrhage. And that's because they give you that sort of lucid period. Um And one of those things that I sort of think about when I think of extradural, I think, okay, the patient's had extra time before they had a, you know, their second collapse and I think okay, both had extra lots of these little things that you just, I think either work for your don't. And I'm a big person of little memory cues and whenever I'm revising my house is full of post it notes, so always worth putting things that you're forgetting around the room and then a juicy ass question. Um So the G C s of zero, I hope no one thinks that. And um I remember being in a, a TLS um scenario and someone said that the G C S was zero and the examiner was like, oh gosh, like how did, how did you get this far? But it's one that you've just got to work out by knowing how to assess them as G C S. So I will show you my weird method for it if it helps good if it doesn't ignore it. So, GCS chart um three bits to it. We know motor, verbal and eye opening and I would love to know who taught me this one, but it's always, I've always remembered it. So I think of a, an old affairs like affairs hat and it's floating down a river, don't know why it's a river. And I think an old fares that's floating down the river will reach the ocean soon. It's something that someone showed me, I think in a lecture and they had this beautiful picture of this little fairs hat. On a boat going down a river and it's just a little pneumonic or edema to, to go through all of the things um that make up the G C S. So it's motor speech and eyes. So I think old Fez, you've got obeys localizes to pain, draws away from pain flexion extension or zero. Then ocean is your speech? You've got oriented confused. The e is for explicit or inappropriate. A is for absolute nonsense and N is for none. And then your eyes you've got spontaneous obeys or, and then the second oh is ouch. And then the last for N is none. It's a bit silly. I still have to use it to work out G C S. I think it's so ingrained in my brain from medical school um and revising for finals and whatever lecture I got it from. Um And that's how I remember it. If you find it useful, feel free to have that story. If you think it's rubbish, then learn it properly and you'll probably do better. But sometimes you do just have to have these little, little aid things and a bone was to just, you know, get the, the recognition of, of, you know what the chart should look like. And I know when I see that I've got one GCS chart for my head, final bit of the primary survey and HLS is exposure um and this is where we're looking for all the other injuries that could be causing bother for this patient. We're doing a log roll. I don't really know any questions or can think of any that sort of related directly to the exposure part. Um, that haven't already been covered in kind of primary survey. But in general, when you're at a primary survey and you expose the patient as a t you know, like minded person, I'm exposing the patient. I'm looking for bruising. I'm looking for angulations of any bones. I'm looking at the ankles, okay. You know, does everything look okay? Is there an open fracture, car accidents? I look at the hands, I think, right, if you hit the windscreen, have you let go of your steering wheel? Have you got to fractures across your hands? Looking at the collar bones, I'm looking for sort of anything that could give me a little hint as to an extra injury, um, and cover the patient back up as soon as possible because they've already been, you know, extricated from a vehicle and it's taken ages and they're cold so quick expose, look at, you know, the patient and then, um, get them to the CT scan, er, or the surgical decision maker as it was often called. So very briefly, um, we'll just touch on shock again. So, um, shock definitions are something that, you know, will come up time and time again and getting your head around. All the different types of shock is important and the sort of caveats I have for that are number one is a patient bleeding or are they not bleeding? And do you need to do something about that? So, hyper, overly Mick shock can be fluid depletion but within a TLS, it's nearly always hemorrhagic. Your hypovolemic shocks could be also your little old ladies on the ward who haven't had enough fluid because you're starving them for theater where it could be people that lost a lot of fluids. Um I've seen people with gastro with really bad hypovolemic shocks really, you know, cool, pale clammy feeling rotten. And then you've got cardiogenic distributive and neurogenic and it's important. Remember that spinal shock is not neurogenic shock, spinal shock is something different in its own entity that I think is probably hopefully going to be covered somewhere better by a neurosurgeon. Um get the definitions in your head, learn them. Um And I think it's important to cover sort of anaphylactic shock as a definition thing because that can come up and I think it would be a whole separate lecture on its own because it's, you know, something again that we can manage, you know, or need to manage quite differently. So I just put that table up again because it's really important and I think that it will come up, you have to know it, you have to just learn it and I don't know, that's all I can say about it. Um Loads of questions about Shaq talk about that table of hemorrhagic shock and the class of hemorrhagic shock. So worth just spending some time putting you know that into your memory and then I will just finish with my general top tips for the exam itself. Um So some people might have done already, some people might be doing for the first time, always read the question twice. Like I said earlier, sometimes it does feel like uh the mrcs is there to catch you out and some questions are really rewording double negatives, which is the least appropriate. What is the next best versus what is the next appropriate? Like just little wording things that can be really frustrating. Um in, you know, in paper exams, I say highlight the keywords. So in a an online exam, even if you're just using your mouth too, like drag over that keyword and think, right. That's the question. Work quickly but thoroughly go through the questions as quickly as you can leave any tricky questions that you are wasting time dwelling over till the end because it's better to get five more marks from questions that you can answer than to spend, you know, loads of time getting yourself really turned over about a question that if it's truly a rubbish question, it doesn't make sense. It my might not make the final cut anyway. So if a question absolutely seems rubbish, don't lose sleep over it. And if a question is hard because you didn't manage to get to that point of, you know, revision. And there is always going to be no matter what exam you do some points that are like, I'm never going to learn this. So, you know, if that's the case park it and move on and I would find sort of the past test pass med mrcs. They're all fantastic question banks. It's really easy to throw a lot of money at them because, you know, it's a really big exam. It's cost you money, you want to pass, you want to progress. So share them between your friends if you can working groups because it's miserable revising. So why not? You know, misery loves company. Company revised together and make a list of all the tropics. You keep getting wrong and cover your house and post it notes with that, you know, guideline, that thing you keep missing and sometimes even for the part a which I'm sure lots of the court trainees wedges whoever will say, you know, all you need to do is do questions. Sometimes you do just have to sit down and do actual old school, make notes revision if something's not getting into your head from questions, um That's okay. Take a break from the question, sit down, learn it, have a break, have a cup of tea, go back to it. Don't be disheartened and it's an exam that you can easily get through. You just have to put the work in and I guarantee you should all be fine. So that's um that's me. I hope that's been useful. I, I hope that you'll doing okay with your revision and I'll be back in a couple of weeks to go through um common breast conditions with you guys. Thank you very much. Thank you so much, Lily. That was fantastic having your, your clinical experience offering those wisdom alongside. It was completely invaluable. So, thank you very much. Um If anyone's got any last questions, please feel free to drop them in the chat. Um But otherwise, as Lilly said back in two weeks time, um and you should be able to sign up already on the medal link to our page Wales FTS S. So it up to the event and then you'll get all the notifications so you won't miss it. Uh Great. No one said anything on the chat also, please get out the feedback. Thank you all. And if you have any questions that you think of afterwards or anyone wants any, I'll put my email address on the next one I do. So you can email me and I'll try and be helpful because I know the rubbish exams, but you'll get through them and you'll be fat. All right, I need to go feed this cat. She's mowing at me now. That's all right. Thanks so much guys.