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Yeah. Hi again this evening. Hopefully, you're enjoying this series so far just to familiarize you that didn't join us. Um, on Friday evening, I'm between one of the F three is currently working in general surgery. And I've put together a case series really with mentors, female mentors that I look up to you personally, and you have been kind enough to offer themselves to help us out. Um, so this evening, it's more looking at core training applications, Um, someone who has just gone through the whole process. Someone who's secured s t three job and has done very well. Um, and they're going to have a chat to you about kind of problems or things that they've overcome as a core trainee, both in applying and also, um, in succeeding in that training. And so hopefully you enjoyed that again. Any questions? I do stress. Put them in the chart early on, and then hopefully we can get some answers for you. And I'm just gonna get up our speaker for this evening and share with them, and hopefully you'll enjoy it. Okay, so this evening, So you're aware we've got a SED called Rebecca. She used to work with me when I was an f one. Um, and she really inspired me. So hopefully she's got something great to talk to you about. Okay, I will meet myself. Hi. Can you hear me? Okay. Let me see if I can share my sides. Okay, so I've not used this before. So if anyone can't hear me or anything, please let me know. Um, I think it's still logging in, but let me just see if I can go forward and back. Yeah, so thanks so much for that introduction, cat. And thanks for joining us, everyone. Um I'm really happy to be here. I think it's a really great idea to have folks from all levels chat, too about their experience is and how to get where you want to be. Essentially. So as Cat said, I'm just finishing CT to start in S t three. In a couple of weeks time, bit of background about myself. I studied in Glasgow, um, from Glasgow, and I did my F one F two in Glasgow as well and then went straight into CT one c t. Two and then I'm going straight into ST three as well so I haven't taken any career breaks, but which is important for future in the presentation. Um, but that's not to say that I wouldn't recommend it. And I think it's very unusual to chat to someone who's not taking a career break now. So hopefully I can give you some insight into how I'm feeling about that and how things have went so far. Um, I did my training in the Royal London hospital for a year, then Hamilton, then Great Ormond Street and my S T three jobs in London as well. So I'm going to chat about core training, the application itself, what to expect from course, surgical training and just a couple of case scenarios, which are kind of common or things that you would expect. Now I can see the chat here. So anyone who is able to would you be able to just right in the chat what your level is, what career stage you're at, whether you're a medical question, if one co trainee or anything else, or the fellow or whatever, just so that I can sort of tailor what I'm speaking to to all of you and just I'll keep an eye on that. If people can post on it when they do so just a quick note as well. Obviously I'll be talking about about women and surgery. I've put my mobile number there in case anyone has any burning questions that they are too embarrassed to say on the child or they don't want to, um, speakers Just to do that. When I was in union, I found it really helpful. And obviously you can tweet me as well at any time. But yeah, the I put a picture of the lioness is up just because, um although obviously I'm Scottish, it was a bit better sweet that they won the women's euros. But that, for me, is a big symbolism that can be drawn quite. Um, it could be just You can draw a lot of similarities from this and surgery. Um, a lot of women women actually started playing football before men in general in Europe, and then they were banned from playing for a while, a bit like women being banned to, um, not like the medicine and banned from surgery for a long time in the 18 hundreds. And now to see them be successful and have so many followers. And you know, fans across the world. It's just it's really good symbol of feminism and what we have achieved so far generally, um, with femininity and we're going to go from here, and I will touch again on why that's important in surgery. But we still obviously have a long way to go with surgery on this. So first of all, just to think about what route you should be going into, um, so if you think where do we actually go from F to a lot of people don't don't know what their training program is going to be or what they want to take. Um, So again, if you're able to let me know what stage people are at, um and cat, if you're still on, I'll just message you Now, Um, just to make sure you're not working, I'm just not used to handle at all right, anyway, so you can go multiple pathways at the end of F two non trading post or training post. So a non trading post is what people commonly due so think about 65% of F two is now. Take a year after F two and they go into doing some locum in where you can make a lot more money. You can be a kind of co teaching fellow, um, or you can do about research or you can do something else. But research is sort of the I don't really know anyone that's done that, but I know that you can do it if you want to, Um, and there's lots of good opportunities to do that. There's lots of things that will benefit you when you take that pathway, which is not having any pressure of having to do certain things when you get into court training under restricted timeline, and again, I'll talk about that later on. But if you do want to go into training, you can either reapply for specialty training, which only some specialties offer. Or you can do core training, which will give you a bit of a broader outset into, or insight into what is out there in terms of surgery. Run through just means that you don't have to apply again when you become to become a consultant. You just start S t one after f two, and you continue that for eight years, and then you become a consultant for me. I chose core training because I wasn't actually sure what type of surgery I wanted to do. I thought I wanted to do pediatric surgery, neurosurgery or trauma, and I got offered a core training job, which had trauma surgery and pediatric surgery, so I couldn't really turn that down. So that's why I did. So. That meant I had to reapply for ST three afterwards, which comes with its own challenges. So this is something that some women will hear a lot in surgery that almost every single woman that I have ever met in the medical profession has had something like this or something similar said to them, Um, just a couple of slides, we'll have these red boxes on them, and these are quotes that have been said specifically to me or to my very close friends. It's not just I heard of someone that this has said to. It's got a personal and a personal sort of point to it, and I think it's really important early on to recognize that we have to talk about these things. We have to make sure they're not normalized and We have to highlight them as much as possible. And if someone says to you, you know it's not suited to family life. If you're doing surgery, you know, if they've got kids, then you can just ask them if if they are a man and just say things like, You know, how did you manage to do it, or what tips do you have? Then if that's the case and this has always been a problem, and we're not really there yet in terms of equality, as I said before. And in fact, the first female surgeon actually dressed up as a man for her whole life. So she applied to be in the military, and she was quite a young sort of boyish looking female. And the early 18 hundreds late 17 hundreds and she went by the name of James Barry. But actually her name was Margaret and or something. Um studied in Scotland and was from Ireland, joined the military, became a military surgeon, was buried James Barry as a man and then underwent a postmortem, and they found out she was actually a woman, so she is actually the first true female doctor or surgeon And that was just before Elizabeth Blackwell, who's the first female doctor. But we still have such a significant problem. The ratio of mental woman in surgery is 8 to 1, and the biggest issue is the higher up you go in terms of surgery. And this is from an American paper, the graph on the right, the less females that there are so still have a bit to work on in terms of equality. But anyway, on to the core training application. So, as I'm sure you all know, um, there are certain things you have to do. Two. There's a check list that you have to follow to apply. For course. Surgical training encompasses things like what exams you've done what presentation? You've given what conferences you've been at, and you get points based on what you've done at each section. So I'm going to go through each section, highlight what point you need and how you can get them and say what I did as well. So, first of all, the things that everyone loves doing is not exams but operating. So if you don't have an a log book already get it because I use mine is a medication, and it's the same account, and I'll use. And I'm about to be a Reg and you log every single case that you're involved in. Whether you're watching, assisting, scrubbing in, whatever you're doing. Logs that case. So get the MRI done at the hospital. Number of the patient. You don't need to know what the consultant is. You just have to know who the consultant as You just have to know the dates, patients, date of birth and their basic information, and you don't need to get it validated online. You can either print it out and have someone right and scan it, which is actually what I did. And it's quite easy to get involvement in 30 or 40 cases, which is what the maximum number of points is here, which is six. That's a huge, huge number of points in the core training application that you can get just from turning up and not doing any more work. You don't have to be there for the entire operation. You just have to turn up, get the patient details and stay for a while and be active. I managed to get, I think, 50 by the time I had applied for core training, but this wasn't actually part of my point system when I applied, But the only reason I got that is because, um, my dad was a builder, so he was building part of this theater in the hospital, and it just so happened I was placed in the same hospital as him. So he used to give me a driving to work and placement, and I would just go there at half seven in the morning, find out what consultants were around, and then, no matter what specialty, I would just go and say, Can I come into theater? And by the end of the week, they were all sick of me. But I know how to scrub. I know how to close the skin. I know how to hold instruments. What type of strictures There were got lots of career advice, so I would fully recommend doing something like that, you know, just spending two weeks to turn up And your surgical placement, Um, and the teaching will come. You know, the more you turn up, the more people we came to teach you. So it's an easy six points to get In my opinion exams, you've got part A and part B part is written. Part B is practical. The party a pass rate is only 30%. About a third of people pass it two thirds feel, which is why it's beneficial to start early. In my opinion, I don't mind at the end of f one, but equally I know the majority of people. I know that it later than that. And they also had the benefit of being an on call surgical S H O revising for their exams and having all this fresh knowledge. I couldn't remember anything when I started training because I've done my exams almost two years previous to that, um, so either choose to do it or you don't, but it's not funded if you do it beforehand. So if you go into course surgical training and you want to do it, then then you obviously get it funded, so you don't have to do it to apply. But it's obviously a bonus if you do, um, placements is kind of something that you either have or you don't have in terms of electives. I didn't have any specific surgical electives. I did a pediatric anesthetic selective. But during that time I would go. I would help integrate the patients with the anesthetist. And then instead of just sitting there or going to get coffee or going to the ward, I ask the surgeons if I could scrubbin. So I put the patient to sleep with any statist and then scrubbed in with the surgeon and then went to see them post operatively. And I logged every single one of them, as on my log book. So then turned into almost half surgical half anesthetics. You need evidence for all of this. So I just wrote at the end of mine that I scrubbed in on X amount of operations and then that therefore counted as surgical as well as an aesthetic case of weeks are super easy to organize. You just go up to a consultant and say, Can I come to your department for a week? It's as simple as that. It doesn't have to be in a fancy hospital, doesn't have to be a broad, and it just has to be five days long. Have a letter from your consultant and then write a short reflection on what you did. It's a good opportunity to do an audit as well, but that can be sometimes quite demanding. I did two tests of weeks before applying for course surgical training. One was vascular surgery in the hospital that I was currently in at the time, and another one was trauma surgery in King's College in London. So I ended up just staying with a friend. And the reason I got that was because I Googled trauma surgeon, email London and found a guy. And he replied, So another bit of advice is, if you don't ask, you don't get and sometimes things just benefit you, and sometimes they don't. You do have to do some courses. You get four points for the different courses that you've been on. I personally don't think this is a great section of the application. I think you can get more points and more beneficial way. I only did I think, two courses or one course even, and I did one called procedural skills for medical trainees because I wasn't really willing to fork out 800 lbs for, you know, a TLS or 600 for basic surgical skills. When I wasn't 100% sure, I wasn't even 100% sure I wanted to do surgery, but I just wasn't in a particular rush. It just so happened I got offered a job. But you have to remember as well that basic surgical skills and a TLS um, they are both covered with your study budget when you do get into course surgical training and they're not guaranteed to be without that, without course, surgical training, but they definitely are when you get there. So, um, I only did those when I got into your training. And then there's also is it, um, which is essential skills for surgeons and training, which isn't run by the Royal College of Surgeons. It's run by Doctors Academy, but it's actually cheaper, longer and covers more things. So I would really recommend that course as well. It was really, really good for me and on a similar note conferences and presentations again, you just have to turn up to these things. You just have to get the best of advice is that I can say is just get one bit of work that you are really proud of or that you think is decent or In fact, just get one that's finished and apply to every single conference you can find, regardless of if it's a surgical one or not, because you can. You know if it's a patient, safety one. But there's lots of surgical presentations. Then you can explain that when you write a reflection about it. Sgb I and it's it's always run conferences, and they're really good for junior doctors and medical students to present at, um, but actually, the one that I've found a lot of success with is the Royal Society of Medicine, which is much more patient safety and quality improvement based. But you always have an opportunity to win a prize, which is where I one to my only prizes when I applied for course surgical training. And actually I only had one at that point. So that's a good place to start is the Royal Society of Medicine and again in the same breath everything that you have. Just send it in to conferences and try and apply as much as you can, um, do a virtual conscious count. Yes, absolutely they do. Um, they are totally fine, and you just have to have the evidence which I'll talk about at the end when I've got a slide on what evidence you actually need. But if you can go in person, then great, because it's quite nice to meet people, um, in Network. But, like really get your face showing at these conferences. I've been to a couple where, um, the same people are now going to similar conferences, and they're going to be on a similar career trajectories to where I will be as well. And it's quite nice to know some people like that, and if they like your research as well, they're more likely to contact you. But yeah, absolutely. They can't. So maximum points will be an international conference. But you also do get points for um, obviously poster presentations. They're good, too, but you do get points for things like journal clubs, M and M's. And again, that's a good opportunity to have a leadership role. If you're in charge of creating the morbidity and mortality meeting and your department, that's still something you can write down. So when it comes to application time, write down absolutely everything that you have done prizes and awards. You get them as a medical student or you don't, Um they've changed a lot since I applied. I think six points was an international prize for me, and then I think below that was, like, national prize and a prize specific to medical school. But things like, um if you had a Bursary for your elective, that counts as a prize because you have to apply for it. So anything you have to apply for that you then get given. I would say, Count that as an award or a prize And just make sure you've got confirmation letters and reflections and things to, uh to emphasize that. And I also would recommend including non medical prizes, just in case. I know that things are not in person now. The interviews are not in person. But when I applied, um, I had I think I had a prize for playing football or something, and they asked me, What else makes you stand out or what else makes you good in this category? I said a couple of things, and then I said, They said, Do you want to, um, tell us anything else about your portfolio that you think we might have missed and I said. Well, actually, I was wondering if you could count this as a national prize because it was like a national team thing that I was doing at the time. And it just shows like the team work in the, um, hardworking skills that I've got and that can be applied to core training. And I'm pretty sure they did count, because when I looked at my feedback, I had more points than I thought I would. So write down absolutely everything that you can. A slide is a bit chunky, um, and hard to read. But teaching and leadership are also really crucial, and we're sort of getting more towards the end of the application, which is arguably the most important part. So teaching leadership and audits, I think, are the three things that everyone should be focusing on teaching you can do at home, so you can just do a random teaching sessions with medical students. Every single one counts. Um, just make sure you get feedback forms for them, which you can print out on the J. C s T website, and that just makes it look a bit more official. So when you upload it for your application. They know that you're not just made up your own teaching feedback form. It's quite empty, so I try and condense it in one page. But then you've also got it saves on your laptop so you can just forward it to any student that you give a bit of teaching to. And once you've got that over six months, it really stands you in good stead. You can also set up teaching groups and teaching societies. All that really takes is getting a couple of your friends to give teaching to medical students once a week. Um, what I did and I'll come onto leadership in a minute is I am an F two. I rounded up a couple of my friends that needed points for their teaching applications as well. I asked them if they could prepare a slide show on a certain topic or surgical topic. I contacted the teaching fellow in the hospital and the someone from the university, and I said, We are teaching group. We would like to give your students teaching once a week, and then I made a rota, and that was a regional leadership role because, um, it was in Glasgow. So and it included the university, which was multiple different areas. It was over three months or however long, four months. Maybe, however long the the timeline actually is. So leadership, regional teaching. And then I audited it as well. I think so. I asked the students a question beforehand, give them some teaching and then ask them the same questions afterwards. So you can be really not sneaky. But you can play the game really well because you don't have time to prepare a lot of these things. And some people will come along having a masters and teaching, and they just walked in with four points. But if you can work hard for a couple of weeks to set something up and then just check on it once a week, you're potentially going to get 10 points for something. And I think that's the second highest or the highest area that you can get points. And other than maybe audits, well, that makes sense. Um, yeah, so leadership you. If you do make a teaching group, I would recommend making yourself the leader or delegating rolls to each other. So having one person be like the contact for the university. One person for contact for students, one person for creating the content, making sure you know that. You know he's learning outcomes so that you're tailoring it to their learning outcomes and stuff like that. You can do that leadership. And that way I didn't have any leadership roles at my stage at that point. So that's what I focused on other than non medical things. And again, I brought that up during my, uh, during the interview, I said, I'm actually club captain of the football team. Can you count that? And they said Yes, so you can do plenty of other things or, you know, being a member of acid or a S e B I. Any other committees or councils. That also is a really good thing to have, Um, but it's kind of difficult to to get that and to get the evidence for that within a year's time, which is probably how long you'll spend thinking about your portfolio and saying, What do I actually need to do here to to score Well, um, publications are probably about 70% luck in about 30% hard work. You, I mean, at University. Everyone I knew was published. It felt like multiple times. I felt like everyone knew what they were doing academically. I had deliberately chosen and interrelated degree, which didn't do stats because I didn't even want to deal with starts at the time. Um, so I was full of regret when I came to apply and and seen that you needed two publications to get a maximum of six points here. I think it's a big ask to ask for these things. Um, but you might as well try. And I think it's important that when you're probably about F two level maybe S H O or CT one level, every project that you should do, including audits you should be aiming to publish. I managed to get my dissertation from my interrelated degree, published two or three days after the course surgical training interview. So I had, like, the confirmation letter and stuff, and they still gave me all of the all the points for that. But I didn't have anything really at the time, so I wouldn't worry too much about this one. As I said, you can get 10 points for teaching, and the paper is going to take you about a year to right anyway. And it's probably the most important one. So audits again, I didn't really know what that was when I was a student, but it's basically finding something that that really annoys you in your line of work. And so, for example, take operation notes if you're a junior doctor or a student on the ward. And the nurse asked you what you're going to do with this patient now that they've come back from theater and the operation. No, has absolutely nothing on it. The operation. No, it has not been done properly. So you have to find a guideline. There's a guideline online that says you have to have this, this, this and this in an operation note. Um, this is one of my audits. I did. I then looked at six months of data. All the patients that came in and looked at their operation notes said, Do they have this in it? Yes. So they have that and, you know, and then presented it to the department. Um, once you presented it to the department and stuck up a few posters, I waited a while and then checked on it again. So any patients that had their operations done after that that I didn't show an improvement. So sometimes you can show an improvement. Sometimes you can't. Um but that's a full cycle audit. So with that, you can. Then you've got your four or six points or whatever it is for doing the audit, then you should submit it to a conference. Um, then you should submit it to a paper to get, try and get it published. And if you've got someone good alongside you like a good raise, your good consultant, they should be able to help you with that. So you're you're really taking all the boxes at once and killing lots of birds with one stone, so that would be an example of an audit. And the more you can do, the better you have to do at least once a year anyway. So what do you need then? Once you've gone through all of the different sections, and what proof do you need that you can do it? Well, they don't specify what you need, but what I took from it was Get all of your certificates ready. Scan them in multiple ways and be really prepared for all of them. Have the contents or the program of the conference, um, stuck and signed and scan and everything Have the presented work that you've done saved. And then get your consultant, your educational supervisor, to write your letter to say, I've done this, this, this and this while I'm on your placement, um, signed by the consultant and right there, GMC number underneath it as well. When I was applying one of my friends that she had, like, eight audits or something, I had one good one, but I did it. I did it fully properly, and I got all my paperwork started and I had no doubt that would be a full points for what I wanted. Um, whereas hers was slightly more messy and she didn't have any consultant letters, so she didn't get any points. So she missed out on a lot of points in that one section just because she didn't have specifically what they had asked for. Um, she's still got a job, but it wasn't the job that she wanted. So it's very important that every single point counts, um, for this now they've put the maximum is 72. But you need to bear in mind that four points a PhD and stuff. So if you can get 10 points for teaching and eight points for a good audit, that is a really it's a much, much better way to spend your time than any other way. So that's the whole application, for course. Surgical training. Does anyone have any questions about that? If not, I'll move on to what you actually do when you get there. Nothing. If you do, then just post them in the chart as we go along. Okay, uh, this is supposed to be an animated side, but essentially, it's a very, very, very difficult two years. Um, you essentially have to start thinking about what you need to do at the next stage of applications. So thinking about applying to ST three from day one and you have to pass these years as well. So you have to do a case based discussions. Many cases and things. Where can we download the portfolio from the specification? Is on course is just on course surgical training. So if you just Google course surgical training person specifications 2022 that will give you did have the link in, but I think it's behind all of this stuff, so I'll try and find it at the end. Um, and maybe post in the chart if I can find a link. So, yeah, you have to do a certain number of case based discussions every year. Um, I think it's about 80 and that includes things like many kicks is teaching, um, sign off for operations called PBS or drops, which is where you performing appendicectomy. And then you send your Reg and online ticket and they have to sign it off to say, yes, you're not actually making this up. The problem isn't you keep it on top of that. It's keeping on top of the people you've sent it to, because obviously they're not going to sign it right away. So when you are progressing through your career, it's important to remember your juniors and remember that they have deadlines. So if they send you a ticket, just do it on your phone right away. Rather than letting it all build up. The red comments in the back are again sexist comments that have been said to myself or to my friends when you're taking a break to have kids. Um, if you don't want kids, I'm sure you will have kids. Anyway, someone once flippantly said, Well, this is what happens when you're operating with women. When the consult, I think the red was a woman, I was there and then there was a medical student and the nurse was there and someone didn't get an instrument in time and then the other one behind. It is a homophobic comment, and then we've got a couple of always, always a couple of sexual assault comments that had been said around where I was once, which was completely unacceptable. Obviously, I'm not put them in for obvious reasons, but it just shows that we really do have to be resilient and try and not let anyone's opinion put you off doing what you want to do. I know it sounds a bit basic, but you have to be selfish sometimes. Obviously you you lifted your claim and you help other people out. But if someone has said something, I think it's really important to stand up and make sure that it's called out and it's reported to your senior escalated just to address another comment on the chat. So, um, okay or not, I'll move on and then you can reward it if you like. So, of course, are you retaining is two years Um, sixmonth placements. Variable choice based on your location. So I did trauma surgery, vascular surgery, pediatric surgery and general surgery in London. It's October to October, but everywhere else it's August to August, so I move on in two weeks' time. But a lot of my friends who are the same levels may have already been a Reg for a month or six weeks or so. And then what is expected of you you have to do. And this is bare, bare, bare minimum. You have to do one audit per year. You have to do these courses like a TLS and basic surgical skills. You have to do exams, and you have to pass them by the time you've applied for ST three. Although they have given some covertly way, I can talk more about exams at the end if anyone has any questions. But I've sort of deliberately not went through it in detail because I think this is quite a lot of information and you don't want to get too freaked out. And you have to do the teaching, of course, but as a bonus, or to be to be competing for a good essay three job or any S e three job, really, you have to have multiple audits. I would aim for two a year. You have to do a bit of research or publications, although I do know some ridges that have never published before. But it does give you I think it's important to understand that whole aspect of of work, especially if you're going to be in London, because London is many things. But I think it is quite good for academics, but it is obviously very poor for learning how to operate, and you tend to do a lot less than your peers who are outside of London and then to get a leadership role. That would also be, um, excellent as well. But again, I didn't really have one. I just made another teaching group because it worked for me in core training. So when I applied for S C three and I had just to teaching group leadership things, although recently I've just been, um, accepted to a trauma committee. So when I become a consultant, at least I'll have that, um So if you have teaching experience during undergrad through teaching medical students and then foundation year, what would you have going on with? Both be counted. So, um, I'll try and explain the way that it's set. So you have you have a tab, which is like teaching, and you just upload all of your evidence. So I would have to say you did medical school teaching and foundation school teaching. I would just calculate them also or sorry, write them all. Medical school teaching 1.0, um, feedback forms and then maybe medical school teaching reflection 1.0 and that use your reflection to explain everything you've done and then do the same and foundation. And you also yourself score yourself. So first, the first thing you do is, um, kind of count how many points you think that you've got up, and then you send that to them, and then you send them your evidence, and if that matches up, they'll try and make it match up. So if you explain why you've given yourself certain point, they were like, All right. Okay, that's fine. But if they think that your evidence doesn't match up, then they'll knock you down or they'll knock it back up again. Does that make sense? Um, you can be scored on anything from when you're applying for core training. Everything you've done in medical school counts everything you've done an F one F two accounts. But when the time comes that you apply for S E three, only thing you've done as a doctor will count, so medical school doesn't count. So I hope that answers your question. Let me know if it doesn't, Um, And if you want to email me another question or if anyone wants to email me any questions, please do as well. So other expectations that you'll have to do is you will be expected to do some practical things. I wasn't really prepared for it, to be honest, because I had only done four months of general surgery as an F one. And then I did a year of neurosurgery, so I hadn't done any general surgery in a really long time. And on my first day, I got asked to put on a chest pain and recess, and I had no idea what to do. So the important thing is you have to be honest with people and you have to ask you lots of questions. Otherwise you won't progress and people won't trust you. I would much, much rather someone came up to me and said, I don't know how to put a catheter in than they put the catheter in the wrong place and the patient. I don't know what is in retention or they perforate something. It's really important that that's how you learn. And that's how you get experience and on the same method. It's important to delegate all your tasks as well, because if you have an F one F two that are doing nothing on the ward but you're swamped in any, you have to just bite the bullet and ask them to do something to help you out. So I'm just going to talk through to clinical examples, and then we'll finish up just to give you a taste of my experience. So two scenarios which have happened to me the last one started twisted to make it a bit more interesting, but, um, these are the things that I had to deal with that have happened, like multiple times or a couple of conditions that I've seen repeatedly. So it will require some, uh, input from the chat if people are able to. So this was taken when I was a CT to it was a referral that the GP called me with and said, I got 45 year old lady here who has a breast abscess. Can I send them in to you? And as a general surgeon, you do cover breast abscesses, you cover breast emergencies. Um, I said, what are the obs? How is she doing over the phone? She has a temperature of 40.8. Her heart rate is almost 100 and 20. She's technique, and she's hypertensive. So would there be anything you want to ask, say, clarify? Tell the GP to do so? Anything you want to say? Or does anyone have any thoughts? What could this be? Um, what are you worried about? Is there anything that is going to be playing in your mind or ringing alarm bells there and to put things into context while people are having to think, um, this is a really busy day. I remember sitting in any taking this referral. Um, and I had, I think, six or seven other patients to see and there's no shame in saying that immediately. I thought breast abscess. Okay. It's probably a small little thing. I guess it can wait, or she can maybe come in tomorrow, and then we can drain it or something like that. But would there be anything in that scenario that would make you think? Probably. We need to see her quite soon. Okay. I'm gonna whiz through it. Um, things that rang alarm bells for me was the tachycardia and the temperature. Because immediately, you already know that she's got Sara's category. So she's septic, so you can tell that she's septic over the phone. So at that point, yeah, the vital sounds exactly, um, if I hadn't known that. So if I had picked up the phone and said yes. First abscessed. Okay, that's fine. Just send her in tomorrow. And maybe the GP didn't have the observations or the vitals there, or they just didn't have them to hand or something, or they thought she looked okay. Um then this patient probably would have died, so it's very important to be vigilant and take every referral, get a bit more information, and don't just go right. Okay, fine. I'll just deal with that later. Which is very, very easy to do when you have 10 or 11 patients to see. And some of them are really sick. So first thing I said to the GP was put her in an ambulance and blue light her to recess because these septic patients can be really, really sick. Obviously, you have to get antibiotics in them within an hour to do the step to six. But the GP told me over the phone. Um, actually, we're closing in 10 minutes, so I'm just gonna ask her to drive, um, which for me was a bit of a red flag. I don't know whether maybe I had heard the the observations wrong or whether maybe the patient looked fine, But previously I had seen a similar patient like this, so I sort of knew at that point I said, you know, no, you absolutely have to get this woman to recess as quick as you possibly can. So I ended up They did manage to get the results very quickly. So if anyone can think of any differential diagnosis, um, that would happen in a 45 year old lady with the breast abscess from the GP that has pretty much severe sepsis happening here with a really high temperature. Let me know this was her. Well, this is a picture taken from the Internet, but it was so similar to what she came in with, um, past medical history. Is there drug history? Is there so good thing she wasn't on warfarin or anything? Because that would have complicated things. She was quite poorly on herself. You know, I think she was unemployed and sort of struggling a little bit in terms of mobility. Her bloods were quite frightening. Her CRP was 550 which is the highest I've ever seen it. I don't know how many of your medical students or anything, but normally a high CRP is probably. I mean, it's over five and lot of places. But if you'd be worried about someone that probably over 50 I'd say, um, I had to put it into context. I had pyelonephritis before and it was 80. So hers was 550 which is so high her white cells are 24. My old AKI, not milk A. I and her LFTs were normal. So again, if anyone has any ideas of the diagnosis, let me know. But you can clearly see here that there is a dark area which gives it away. Really? So in someone who has any skin changes like that, Um, if it's black, it's necrotic. That's just a general rule. Same and vascular surgery. And if it's necrotic, it is going to erode away at your tissues. So this woman had the necrotizing fasciitis and she was referred as a breast abscess. So don't take absolutely everything at face value is what I would say, um, for me. When I was learning, I wasn't sure whether she would come under medicine or surgery. But obviously, anything that's necrotic, you have to cut it out. So it does come under surgery. But obviously you would still want to chat to people like the microbiology team, maybe the endocrinologist if her glucose levels were really high. To find out what the protocol was, you need to start her on hefty antibiotics very, very quickly, and you need to consent her for a major operation. You might even have to get plastic surgery involved in a procedure that that big Because that whole black area all just has to go in the bin. So, Yeah, I met the plastics. Yeah, I think we ended up doing. We did the debridement as the general surgeons. And then she got referred to plastics after that for the cleanup. So they made it all looked really nice after we had just chopped things out. But, you know, these patients need a significant amount of resuscitation, and they need a lot of fluids. You need to be very careful with her. Balance is. And yeah, it's going to be really, really painful for them. And they will need probably quite a lot of psychological support as well. Especially the location of where this was. If you're a plastic senior staff nurse, feel free to take over anytime. You can give me advice any day of the week. Uh, scenario number two, another one where plastics potentially could be involved. So we're now and trauma center. We've got a 28 year old male who has come in motorcycle versus car, and he's a code red trauma call. So if anyone can. If anyone has any burning ideas of where the injuries on this patient are likely to be, let us know in the chat, you can clearly see from the picture of this incident that it was very high. I've lost a high mechanism injury. The car is really damaged and you can't see where the motor cyclists is. You can see the windshield isn't broken, but they've clearly gone straight through the front of the car at a really high speed. So I'd be really worried about that. If anyone hasn't worked in a major trauma center before, there are different types of trauma calls. You've got a normal tramadol, which is a normal like adult falling over. Just very basic may be isolated injury or one or two injuries, and then you've got an advanced trauma call, which is a significant mechanism, someone who's really injured. But they're they're stable, which is probably what you'll be dealing with a lot as an S H. O. So that could be it could be someone with an isolated amputation, even though they're stable, or it could be someone with a significant head injury or someone with some rib fractures and a pneumothorax. Very variable. But a code red is when someone is so injured that they are consistently hemodynamically unstable. Um, what was the one thing that you would want to give this patient? What? What one treatment do you want to give them right away? If anyone can think so, you get IV access. What 11 bit of medicine or drugs or anything Would you want to give them? Um, another question to think about is how would you assess this patient? So what are the common injuries in the chest and in the abdomen, for example? Let's say all of his limbs are intact and, let's say, a GCS 15 as well, which is very unlikely, given that he's so hypertensive. So so his heart rate's 140. His BP is 80/40 and he's looking very, very pale. What? One thing that we have to give Someone who's hypertensive had trauma. Yeah. So anything else now that you've got blood, um, you would give it a 1 to 1 to one ratio, and you would also give you a code Red Trump called. Does stop theaters as well and get your loads of blood while people are thinking what else we can give em posits theaters and some hospitals are in most hospitals. The theater staff will come down to recess so that if you have to open the chest or if you have to do anything immediately, then they can do it in the respect. But the key here is giving blood so that the most common cause of, um, death in trauma other than older people who are falling from short height, which is actually just overtaking young patients for most common cause of death in trauma is hemorrhage. So we're right about hemorrhage, and there are three main places that hemorrhage can happen again. If anyone knows or wants to guess, please do, Um, but particularly with this patient, you're going to be worried about chest and abdomen. My animation didn't work in the last side, so I'm just going to keep talking while we're on this side here because I know what's coming in the next one. Um, so let's say this patient goes and you give them blood, and you also give them platelets and cryo precipitate as a 1 to 1 to one ratio. So you're giving them blood products as well as red blood cells themselves as well. And the new guidelines? Well, a TLS guidelines say that you can still give IV fluids, but actually, they do not make a difference at all. So you have to give blood and someone was hemorrhaging. Um, so you go and you get you get a CT scan for this patient. Um, and this is what the CT scan shows. I know it's a bit small, but does anyone know the diagnosis? It's sort of like a spot diagnosis in the CT scan. And if I give you a hint, were in the abdomen, and it's the most common blunt injury that someone can receive in trauma. It's the most common organ that gets involved in trauma. We're also acidotic, so we're worried about them. Is lactase high? We're still really worried about him. I don't know if you can see my mouse on the screen, but 1.2 right here is the liver. So the liver is on the right hand. Side is through the big one. This well demarcated bright circle in the middle is the abdominal aorta. Well, it's just in front of that with the rookie, which is fluid filled as the stomach and then to the back right of the picture, you can see that it just looks like mucky loads of different colors. That's a Grade five splenic injury. So they've completely shattered your spleen, so they probably have to go to theater. And then the last slide is something that you also make it asked to deal with. Um, he wouldn't be GCS 15 with a BP like that, but let's say for talking sake that he has, um, he is now refusing any blood. So you're just about to get the blood and he says, No, no, no. I'm a Jehovah's Witness. He's got full capacity, but the patient's hypertensive. He's pale. He needs to go to theater for a lap laparotomy to get spleen taken out. Who do we want to tell? Who can we tell you? What can we do? Can we still treat him? Do we have anything else we can give him instead? Um, there are lots and lots of answers for us, but it's the last slide, so I'll give people a minute to think like so I think I was prepared to get answers to get asked this in my s t three interview, but it can come up in court training interviews as well. And you just have to know that basically, you don't have to make this decision as the S h o. You have to tell your Reg internal consultant, but there are other people that you should get involved. You have to get the senior nursing staff involved. You have to chat to the patient. Definitely. Let's say for this scenario that he is completely refusing completely confusing. Um, at that point, if someone is completely refusing, then there are. You can get legal. Yeah, exactly. You can get legal and ethical involvement here, so every hospital should have an on call hospital solicitor, especially if it's a major trauma center. And they should be able to give you advice. And you can also call, like GMC or the B M A. And they can. The hospital sister can come in and chat to him. You can Yeah, you definitely believe the right. So if this patient has full capacity and he's refusing something, they have the right to the, you know, their autonomy there. We have to fully respect what they want to do. Um, but it's important to clarify with them. If you don't want blood, what do you want? So we can give you plasma? We can give you plasma content. So, like different blood factors, coagulation factors. We can give you chronic precipitate fibrinogen, things that help make the blood clot. Um, so you can have blood products. You can have things that stimulate the production of red blood cells so you can give them a referral putting injections, and you can also give them iron transfusions as well. But the problem with those two is that the problem with all of this is that none of them work as well as blood. So yeah, exactly as you're saying that we have to explain the risks. So you have to tell everyone who is involved in this. You have to tell your consultant you have to get a member of the ethical team along some of the nursing staff, potentially patient's family and the patient Make sure they know that, and it's fine to say this phrase. I've said it before. Two people in the past. If you do not get this treatment, there is a high chance that you'll die. And you just have to say that and B, you have to be straightforward and direct with the language that you're using. And then if they say absolutely, then I still want it. Then you can say, Okay, here are the alternatives, which is what we've talked about so blood components, blood products and then substitutions. And you can also get something called a cell saver, which is normally used in the elective setting, which takes out the blood and cleans it and puts it back in. But the problem is, he doesn't really have much blood left, so that's not really an option in this now. So active communication exactly explaining the rights, respecting the patient's risks. But ultimately we do want to save them. So we have to be aware that there are other options available so all we can ask as an S H. O. At this point is we escalated right away. We give the patient respect and say, Is there anything that you do want? And then you can call your red or you can call a consultant and say this patient refusing blood. But this is what they're going to have, um, instead. And then you can call the hematology and get the ball rolling rather than just sitting there being like, Oh, no, I don't actually know what to do now and the patient's actively bleeding in front of you. So just be aware that there are other options out there for for scenarios like this, because it isn't that uncommon. This happened to me maybe three or four times. Not in such an acute scenario, but where patients have refused but completely agree, acting very quickly and making sure the patient said you were here. Yeah, even if you disagree with what they want, you have to give them respect. That is, part of our job is part of what we have to do. So just to conclude, um, and again post any questions at all and the cat would like advice I would give people applying for your surgical training is know what's required for the next step. So that includes, um, knowing the course surgical portfolio, which, when I close down the slide show, I'll try and post a link in the chat. If I can. If not, I'll try and post it on Facebook event. Um, there's absolutely no rush to the next step. So if you're an F two and you're not sure I would apply Just so you know what the process is like, which is what I did. I was actually going to go to Australia, but I just I got offered a job, so I said yes. And I've stumbled into ST three training without taking any time out either, which wasn't exactly the plan, but I don't really regret it either. Um, do what you enjoy, not what people tell you to do. Um, I've just completed the masters in trauma. Well, just about to complete it. And when I told people I was doing that at the start as well as Coal Train and they were like, Why are you doing that? Stupid. But yeah, it was hard, but it was so enjoyable. It's really, really fun. And I don't know what people tell you to do. Obviously do what you want to do. Keep an open mind. I was convinced I was going to be a pediatric surgeon when I left. You know, me and and Then I did neurosurgery. I was convinced I was going to do a neuro surgery. And then I had trauma and sort of found where I belonged in a way where it was like a mix of everything that I really wanted to do. But I didn't know that until later on. So keep an open mind for every specialty. And don't be put off just because people and a lot of men say to you, Oh, it's really hard or you need You can't do that with the family and stuff because that's just constant. And I'm fully expecting that up until I'm a consultant and the ones in italics are three phrases that bits of advice people have given me in the past. Um, keep it simple and keep it safe. This was said to me when I was an F one by a cardiology s h o. Who was amazing. Um, he helped me load when I was on the night shift. I didn't know what to do with a deteriorating patient, and he just said, Just keep it simple and keep it safe, and I'll be fine, which is really common to be prevent the worst case scenario was said to me as an effort to, um, which was said to me by a neurosurgeon when again we were talking about what to do if something happens, or because I was worried that someone would collapse and I wouldn't know what to do. Um, so if someone has chest pain, go and make sure they're not having attention with the atarax and not having to pee. Once you've done that, you've got a bit of breathing space. So make sure the worst case scenario is not happening. And that's with any 80 assessment you're doing of any patient. And then lift your claim is something that said to me by one of the best mentors I think I've ever had, which is just, And they're not even the best mentor because I've worked with them loads. I just bumped into them a few times, but they have actively emailed me or messaged me and just checked up on me every few months and said, What project are you working on? How can I help? Do you want any advice? And that's all it takes. And I think that's really important because, you know, being an F one is absolutely terrifying, being enough to you feel great on top of the world. And then you start applying for your training or whatever you want to do, and you get another shock and then you go into court training and you're expected to do an appendix or to put chest pain and some one or two assist in doing all these things, and you're back to being terrified again. So it's important to remember what stage everyone's at and make sure that there are people below you which are being successful, and you learn how to be a mentor in that way as well. So I think that's really important. Um, and other than that, that's all I have to say after talking for a very long time. So, um, if anyone has any comments, questions, anything, please, please, let me know. Applying for core training is really difficult, and then core training itself is really difficult. But it's also a lot of fun, and you'll learn loads. Um, so, yes, and I'll see if I can go back to put my email address. Um, at the beginning of this works, just in case anyone needs anything. Yeah, there is, if not, Thank you so much for coming along and spending your evening listening to this. And, uh, I wish all of you good luck and with exams, with applications with anything. I'll stay online for a while. I'll try and get the link posted and shot and have a great night. And thank you. That's the link in the capsule. But that's obviously all of this is based on the older ones, too. Uh, the older years so might change. Okay. Thank you so much.