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Ok. Yeah. Ok, sorry. Um Yeah. Uh Hello everyone. Thanks for joining. Um I think we'll give it like one minute maybe to see if anyone else joins and then we'll make a start. Ok. We'll start at 03. Ok. I think we'll just make a start. Um So, hello everyone. So my name is Patty. I'm one of the fifth year medical students. I'm based in Preston. Um So this session is gonna run a little bit differently to the other code blue sessions. So this one is a collaboration with Preston Oncology Society. Um So obviously I'm part of that group as well. Um But otherwise it's exactly the same format. It will be a little bit of teaching on some clinical skills and then we'll split into breakout rooms um just to practice those same skills. Um I would highly recommend that you do during the breakout rooms. Otherwise this teaching doesn't really make a lot of sense. Um And it helps a lot to practice especially for the session. Um So, yeah, so this session is gonna be all about oncology. Um It is tailored towards the Manchester curriculum, but it's applicable, not just to oncology, but to all specialties as well. Um So, yeah, so the focus of this teaching is gonna be two main things. One is sbar and your oncological emergencies and the other is gonna be ethics in oncology. So, again, very transferable to other specialties, not just oncology. Um So yeah, the reason we chose these um skills for the session is that we didn't find that we get a lot of teaching in it um in medical school, but obviously, Sbar and patient discussions are very, very important in clinical practice. Um And also in your Manchester Os as well and every other medical school too. Ok. So starting with your Sbar station, um I'll try and make this as interactive as possible. So please do use the chat function as much as you can. Um But yeah, so in terms of SBAR, so if you haven't heard of SBAR, sbar is one of our sort of structures or pneumonics that we use um as a guide for handing over patients to colleagues or discussing patients with other colleagues. The reason it's really important to have a good structure when you're talking about a patient is because if you imagine you're sat in the doctor's office, loads of other people in the room with you, lots of panic, lots of phones ringing, things like that. There's a lot of things going on. You wanna make sure you're communicating all of the important information about that patient, everything that they need to know in order to understand the big gist of sort of what's going on and what's important to deal with first. Um So sbar very important. Um If you're here from Manchester, you don't necessarily have to use an SBAR format as long as it's structured. Um you'll still get the mark for it. But yeah, so again, I love what I'll be saying is tailored towards Manchester. If you're not from Manchester, still applicable. Um but you can ignore some, some parts. But yeah, so one of the new stations for year four in Manchester is your sbar station or it's otherwise known as the colleague discussion. What happens is you'll get some data about a patient. Um lots of information including their clinical history, um investigation results, examination results and something is going on with this patient that you want to discuss with a colleague because you are just an F one and you are concerned that you need senior input for this patient. So you're ca you're calling a registrar or the consultant, probably the reg um and you're handing over this patient. So what happens is you have like six minutes, 4 to 6 minutes to understand what's going on form your sbar structure. Figure out what you're gonna say and then you have two minutes to discuss that patient on the phone, on a physical phone in the station. It will ring at six minutes and then the examiner on the other side of the screen is gonna talk to you. Um Yeah, so one thing that always happens in your SBAR station is they're gonna challenge you on whether or not they really need to come and see your patient. So that's one thing to always expect is they'll ask you one or two questions. Usually it's something like um can you not just give this patient like some medication to help with their pain or their fever? Um But you need to respond in some way to highlight the urgency of the situation and make sure they come and read the patient. Another common thing is they'll say uh we can, we're quite busy right now. We can come in like three hours or later in the day. Is that ok? Don't just say yes. Um You need to push, keep pushing until they say yeah, we can come in like half an hour. So they say around 15 to 30 minutes is a good time frame for any sort of urgent or emergent situation. Ok. So tips for the station and I will go through the actual station. Um I did this in sort of a weird order but tips for the station is keep it very, very structured. Yeah, so really important in an AUS station, make sure you have all your notes in front of you. You know exactly what you're gonna say and you're not gonna miss out any important information. You'll get loads of information in the station you need to pick out what is important and what is irrelevant. So it's not as relevant to say, the patient's got this big long list of medications or this big long list of surgeries they've had in the past if it's not related to their presenting complaint, irrelevant, um for your asthma. Uh So yeah, and yeah, as I said, you must ensure your pa your senior accepts the patient for review. Otherwise you're gonna fail the station if you just say, yeah, I can give them some paracetamol. That's fine. Thanks for your help, automatic fail. Um Or if you say yeah, that's fine. You can come like tomorrow, that'll be fine. Fail. You have to make sure that you've highlighted. It's important they can review the patient and that they actually do. Um Yeah. And of course, if you have any questions throughout, I know I yap a lot and just write questions in the chat. Ok. So this is your SBAR format in your actual ay station. I would highly recommend getting a piece of paper which you'll get in the station physically, draw this on your paper. So split it into quadrants, write SBA R and as you are reading information, um the clinical history that's given to you write it down in the format of SBA R. So you'll get these slides if you fill in the feedback form. Um So don't worry about missing anything. Um So this is just a quick summary and we'll go through each one as well. So s stands for situation. So when you pick up the phone, you need to make sure you are calling the right person and they know who you are. So, hello, my name is Patricia. I'm the fy one doctor in the emergency department. So your location is very important to you if you're in a different hospital, if you're in GP, that has a big impact on how quick they can see your patient or what you can do for that patient. Um So yeah, so could I confirm who I'm speaking to? So this is John and the med Reg on call um and be polite as well. So nice to speak to you, John, would it be ok if I just discuss a patient with you? So ask consent as well is always polite. Go ahead. Um So this is regarding um Susan Smith hospital number, date of birth, 1234, et cetera. So very very important to confirm the patient's ID and full name. Yeah, so obviously you don't, you wanna make sure that they are um aware of the, the correct patient? And also if they're writing down notes or looking up notes, that's important too. Um Again, where is the patient? So they're currently in the emergency department at this moment in your initial introduction. Um Again, if you remember the context, so you're in a really busy doctor's office, loads of people screaming in the background and then suddenly they hear, oh I think this patient is septic. They're listening to you, their ears are perked. Um So at this point, you need to say if you have a diagnosis, what is the diagnosis or gonna mute this ethanol? Yeah. So if you have a diagnosis in mind, I'm concerned this patient is septic. Would you be able to come review this patient? So put it there if you don't know the diagnosis, that is perfectly fine. I didn't for my year for Os and I still passed the station. All you need to say is I'm not sure what's going on with this patient, but I'm concerned they are deteriorating. Would you be able to come review this patient? Because that's fine. You're an F one, you're acting as an F one in your Aussies. Um And the reason you are calling is because you are concerned and you won't see in your input. So it's fine if you don't know all the answers. And then are you happy for me to give you more information? I find it's always really nice just to stop there and then ask, can I tell you more rather than just go in straight um to more history and more background because again, remember the context you're in a doctor's office. Um They, they're rushing around. If you say, can I give you more information at that point, they're gonna grab a piece of paper and then they're ready to write stuff down. That's important. That's why I do it in real life. Um, in an Os. It is just polite and, mm, I'm not, I assume you get March for, like, being polite as well. Um, yeah, but don't quote me on that. Um, ok. So b is your background? So you've told them the situation you're concerned and you've told them what you want them to do, which is come and review the patient background. So again, you'll get a big clinical history, only, the relevant information should be included in the background because also the point of sbar is to make it efficient and quick. You, you don't have time for a 10 minute presentation on this patient's entire life history. What is happening now? So how did they present this patient came in with this, this and that, how has it changed since then? So initially, they had chest pain now, they are experiencing um drowsiness and they're in and out of consciousness. I'm concerned at that point because they are clearly getting worse. Um And then what is their important past medical history? So if someone presents with chest pain, cardiac risk factors are very important. Previous cardiac history is gonna be important in the context of oncology. You bring it back to this uh session, previous history of cancer chemotherapy recently, um et cetera, family history of cancer. That's important in the medical history. Um Yeah. Uh So you don't need to include things like examination findings in this part that will be in the next part, which is your assessment. So, yeah, so how did they initially present, how has it changed since then? And why are you sort of concerned on that point? Yeah. Ok. Assessment. So assessment is where you summarize all of your investigations that are important to your presenting complaint. Um So again, you get a big long list of things. So they might give you a news chart, they might give you um like what do you call it like images. So for example, in my first in my E NC um sbar they gave me neutropenic. No, it wasn't neutropenic, it was sepsis in a child. They gave me blood results, temperature new score in my second OS. So that was M and M I got, I think it was retinal detachment. So you got an image of the, what do you call it? The ophthalmology thing? Yeah. So you got an image of the eye, the back of the eye. Um Yeah, so anything that they give you there only what's relevant and you need to interpret it, it's not enough just to list all the information they've given you in all of this, interpret it. So again, structure is really important if you start with news and then go down to news, examination findings and then any imaging and anything else. Yeah, sort of follow that order. Um So just like you do in any other um station beds, bloods imaging in that order. Yeah. So what did you start off with? Ok. So new score they, they might give you a physical news chart and then you just read off it or they just give you the news and then the, the things that are abnormal in this don't say they're scoring 11 on news. Their heart rate is this the respiratory rate. is this the temperature is this that is not very helpful for the person on the phone. Yeah, they want to know what is abnormal. So the patient currently has a new score of four due to being tachycardic at 100 and 20 they've got a fever of 38 degrees. Yeah. So interpret your new score and summarize it in that way if that makes sense. Um Yeah, other, other domains are within normal limits. Um on examination. They found that this patient again, if we're doing chest pain on examination, um this patient has uh weakness in their left face or they got like tenderness somewhere, I don't know, tenderness on palpation um or they're sweating, they look drowsy, et cetera. So what examination findings are relevant? Um Negatives aren't important always um only if you're ruling out important things, but it's mainly the positive findings that you want to include in this part. Um And then anything else that you included? So for example, in the retinal detachment, um the retinal image showed a bulbous retina consistent with retinal detachment. I'm concerned this patient is deteriorating due to this. I'm concerned this patient is having um retinal detachment and that they might have permanent visual loss without intervention. So end it with your concern just to wrap it up and bring it back to your focus point. Yeah. So I am concerned because of this. OK. Cool. Um And then R is your recommendations. OK. So recommendations. It's sort of a summary of everything you've talked about before. So, SBA R, you've told them what you think is going on with the patient, how their situation has been and what examination findings support your diagnosis. Now, you're saying what you want them to do, you want to do for that patient? Um So yeah, so again, keep it structured, state your diagnosis again and how you think the patient is doing. So usually they're deteriorating. So this patient has experienced um uh A CS and is currently deteriorating. Um They need urgent review by the cardiology team. And then what do you want? Are you able to come and review this patient in the next 15 minutes at this point? They might challenge you. So we're really busy at the moment, we can come down um at the end of the day at that point, you cannot back down. So expect that they will challenge you don't back down. Um I, no, I'm concerned this patient is getting worse. I need you to come urgently. Can you come in the next 15 to 30 minutes? And then usually if the examiner is like, not feeling it, they'll just be like, yeah, that's fine. We'll come. Um Yeah, they might be a bit mean and like get into the acting, but usually they will accept you after once. Um they might ask you another question. Usually they ask you two things. Um So one is gonna be to push you and the other is like, for example, in my sepsis, one they said, can you not just give this child paracetamol to bring down the fever? You, you have to be like, no, because I'm con they're septic and that won't be enough and they're getting worse. Um So can you please come review the patient seems to highlight what your main concerns are? Um And make sure you get that point across. Um Yeah, I think I can't remember what they asked in the retinal detachment. One I think it was to do with like differentials. It's something they can ask as well. Um I think one time they had M SCC which we'll get on to as their sbar. Um So sbar will also be in both of your ay, so one in EF C one in M and M um and that's a guaranteed station. You also do it in fifth year. Um Yeah, please ignore the beeping in the background. I can't mute the the teens chat Uh Yeah. Ok. Um Yeah, so you've asked them for a review um and then confirm your plan with them. So remember the context of where you are, if the station says you are in the GP, that is important if you want to get them to the hospital, so confirm whether you want to transfer them to the hospital if you're in the hospital and you just need like someone from a different ward. Um Can I send this patient to the Oncology ward? Um If you're in GP are you happy for me to blue light this person, this patient via ambulance to the hospital or how would you like me to transfer this patient to the hospital? So confirm the plan, consider the context and your location and then reconfirm the plan. Yeah. So to confirm, you're happy to review this patient in the next 15 minutes and they will say, yes, that is fine. See you soon. Thank you for your time. Make sure you say thank you and then they will put the phone down. Um Yeah, and that's it pretty much. Um So I'd say the thing about your sbar station is it's a very easy station to pass because as long as they accept the patient, you will pass the station. Yeah, disclaimer, whatever I say is like not from the university that's from experience of like student led teaching, you know, take it with a pinch of salt, but like I almost guarantee if you, if they accept the patient in the next like 15 minutes fine, you'll pass the station even if your recommendations are not thorough. Even if you don't know the diagnosis, you have been safe as an F one, you have gotten your support. That is what they're looking for in all of your sy stations is that you can be a safe f one doctor. You can be a safe practitioner. Yeah, you might not know all the answers that is fine. Um For, for most stations. Um Yeah. Ok. Also in your recommendations. Yeah, I was just gonna come to that in your recommendations. Um need to ask, is there anything you, you would like me to do for the patient in the meantime, while they're waiting, they will 100% say is there anything you want to do for the patient? Um and that's why you need to talk about your management plan. So for the context of oncology, they're only gonna ask you about oncological emergencies for oncology. Um So it's really, really good to have a really nice structured way of managing, managing um each of your oncological emergencies. Um I'd say for all of your other specialties as well in this year, um Make sure every time you see an emergency list it down because anything can come up in your sbar. Um I would say for the reason I put this in the oncology session is oncology is mostly a post graduate specialty. So for medical school, the most you need to know oncology wise, aside from the common cancers in other specialties, for oncology as a specialty, it's just your oncological emergencies. You don't need to know anything about immunotherapy, radiotherapy, nothing like that oncological emergencies. So know them really well because you are most likely going to get tested on your oncological emergencies, either on sbar or data interpretation, I would say. Yeah, my oncology station was data interpretation. It's basically the same as this just without the patient handover, it's just data interpretation as you do in third year. Um So yeah, but we'll get into that. Um Yeah, so I hope that answers your question. You do need to give some initial management options. Um That is to get you your excellent points. Um If you don't have the exact management fine, you just won't get excellent but you'll still pass. Um But you do still need to give some suggestions even if it's like, oh I take routine bloods, look for infection markers, things like that, just BS your way through it. Um But it, it helps if you actually know your management plan um for that if that's OK. Yeah. Does that make sense? Um Yeah. OK, cool. Uh I think this, if you Google Sbar, you'll find this and this is a really good like script for it. SBAR is basically as long as you have a good script and a good structure is fine, very easy station to pass. Um Not so, not so easy to fail. As long as you know, again, as long as they accept the patient and you, you like stand your ground, you'll pass the station. Yeah. Ok. OK. Very quick recap on your oncological emergencies. This isn't in a lot of detail. Um Yeah, because the focus of this session is your sbar but obviously in the osteopro component of this, it helps to know your oncological emergencies. Ok. Very quickly. Um So a 42 year old patient with a background of breast cancer presents to ed nine days post chemotherapy with a cough. What are you considering for this patient? What's happening with this patient? If you can play in the chat? That would be great. Anyone? No, I'm gonna wait until someone answers. Mhm Yeah, good. So you got neutropenic sepsis, pneumonia. Yeah, it could be both um causing both. Yeah. So obviously this is in the context of oncological emergencies. You've got five main oncological emergencies that are gonna come up. Um So recent chemotherapy with any signs of infection, even a cough, for example, pneumonia or a respiratory infection, you're thinking of neutropenic sepsis or febrile neutropenia. So what is febrile neutropenia or neutropenic sepsis? So, just like any other sepsis, sepsis itself is a widespread inflammatory response with end organ sort of like failure or end organ damage. Um So yeah, so, neutropenic sepsis is in the context of someone who has an I A compromised immune system. So very important in oncology patients. So I was on M AU for three hours. I saw two patients with neutropenic sepsis is a very common emergency to actually deal with. Which is why when you are in f one very important, you know, the management plan. Um so, so Nitin sepsis, as it says, it's atypical sepsis in someone who's immunocompromised. If you think about someone with a healthy immune system versus someone who has not a healthy immune system. So if someone's on chemotherapy, what chemotherapy does is it targets not just your cancer cells, it will target any cell in the body with a very high turnover, your white blood cells included. So all of the side effects you get from chemotherapy, it's cause those things have a high turnover. For example, you get a lot of diarrhea, um tummy problems because your gut lining has a high turnover. You get hair loss because your hair grows a lot um skin as well. Um and immune compromise because of your white blood cells. Um So yeah, so risk factors for neutropenic sepsis. In practice, you, you have a very low threshold for suspecting neutropenic sepsis. Yeah, very important not to miss it. So you'll read different things on different places. Some places might say 5 to 10 days after chemotherapy, other ones will say 7 to 14 days after chemotherapy is your highest risk of it. Um Speaking to one of the oncology consultants, they told me to add that it is within six weeks of systemic anticancer therapy is what that stands for. So, very low threshold for neutropenic sepsis. Basically, if they've had recent chemotherapy in like the last six weeks and they've got either a fever or any sort of signs of that, they've got infection like even UTI or a cough, um, neutropenic sepsis, you treat it um, as nutri sepsis. Ok. So yeah, so again, if you imagine someone with a faulty immune system or less healthy immune system, they don't form the exact same responses that you will when you're ill. So if you're ill, you might develop a fever, you might have a cough, someone who's immunocompromised, might not have any of that. It might be something you pick up incidentally. Luckily in oncology, you do a lot of routine monitoring so that you don't miss stuff. So they could just present with a fever over 38 degrees. Um And on the bloods, you see that they have a low neutrophil count that is neutropenic sepsis. By definition, they could have signs of say like pneumonia, cough, um fever, feeling unwell, they don't necessarily have to feel unwell, so very low threshold to treat. Um So yeah, any signs of sepsis as well, obviously treat it. So, investigation. So you would manage this like sepsis, six. So it it is sepsis. So you manage it like you would any other sepsis. Um So sepsis six is the main thing to mention um in all of your oncological emergencies and all of the emergencies, to be honest, is escalate care. So again, I keep saying this but remember the context, you are an F one daughter in your Aussies at Manchester. So you do need senior support probably. Yeah, escalate care to who's relevant. Um Obviously you are ringing the med bridge but for example, you might also wanna bring oncology. Um You know, you will bring oncology. Um Yeah, you might need ICU support, you might need an et cetera um transfer tree as soon as possible. Don't wait for a confirmed low neutrophil. So neutrophil is less than 0.1 ish. Again, you'll see different thresholds but like low neutrophils. Um Yeah. So this I got neutropenic sepsis in my aus last year as a data interpretation. All it all it was was loaded fills and they had a fever. That was it everything else was normal. So treated as neutropenic sepsis. So history is really important if they have cancer. Recent chemo easy to spot. Yeah. Um management again say sepsis six. So give three, take three. So give antibiotics, fluids, um oxygen take blood cultures, measure lactate and urine output. Um And then if you wanna be fancy specifically for neutropenic sepsis, obviously follow local antibiotic guidelines, but typically you would treat with um a very broad spectrum and strong antibiotic. So these are carbo penems which you typically use for neutropenic sepsis. So, piperacillin with tazobactam um because they penetrate like the bugs that typically go with n sepsis. Don't ask me enough about antibiotics. Uh But yeah, so that's typically what you see on past med is piperacillin with tazobactam. Ok. Sorry, I talk a lot. I know. Um 72 year old male presents the GP with two week of thoracic back pain, waking him at night. What do you think this could be? Spinal med? Yeah. Any do you know the specific term when you think about the oncology emergencies? Yeah, multiple myeloma. That's a good differential. Mm. Again, in the context of oncology emergencies. What's the specific emergency that you are concerned about? Yeah, good. So spinal compression. Yeah. Um So metastatic spinal cord compression. So obviously spinal cord compression doesn't have to be by METS, but this one is metastatic which is when you get metastases. Um or yeah, usually metastases which compresses the spinal cord above the corda equina, but it can occur anywhere on the vertebral. The reason I put thoracic back pain is if you think the most common site for spinal metastasis is your thoracic vertebra. Yeah. So that's why red flags for back pain, thoracic back pain, pain, waking at night, pain, that doesn't get better with anything pretty much. So like unrelenting is that word unrelenting back pain, um pain, worsen coughing, et cetera. Yeah. Um and obviously any of the like red flags for cancer, fever weight loss, night sweats, et cetera, et cetera. Um, yeah. Ok. Um, yeah. So what is M SCC? So metastases compressing the spinal cord risk factors is any previous history of cancer? It could be recurring. Um, so they might have had cancer 10 years ago. Oh, but it might have come back. Um, or it might be a new cancer they don't know about yet. So, in this history, this person haven't said they had cancer but M SCC can be the first presentation of cancers, especially prostate cancer. So in an older man with red flagged cancer, back pain M SCC. Yeah, obviously not the first thought but in this context. Yeah. OK. So yeah, presentation just all your red flag symptoms of back pain. Um and a history of cancer or even family history of cancer you can ask as well. So investigations urgent MRI scan, you can't, you can't actually book that as an F one doctor. However, in your recommendations, you would say, I think this patient needs an urgent MRI scan. Are you happy for me to arrange that? Uh Yeah, and management high dose dexamethasone. Um Yeah, pain relief as well. So obviously it's always nice to be holistic if patients in pain, if they're vomiting, give medications for that um especially in real life. So pain relief, analgesia, you might give antiemetics if they're vomiting. Um Yeah, and then so a more definitive management high dose dexamethasone the way it works is it reduces the inflammation of the tumor. So a lot of the swelling of the tumor is to do with inflammation, not the tumor itself. So, DEXAmet suppresses inflammation and hopefully will relieve a lot of the pressure on the spinal cord. In the meantime, before you can do all your definitive management, which might include surgical decompression, um very important to escalate. You might even want to say um I would want to contact the local M SCC coordinator. That's a thing in every hospital. Um Yeah, it's just one clinician who is the coordinator for any MS CCS and they will group together. Um But yeah, otherwise just say you wanna call oncology or even the surgery team as well. Yeah, definitive management is to deal with the tumor that has arised. So chemoradiotherapy um to shrink the tumor. Yeah. Otherwise, yeah, not much else you can do with MS C aside from high dose dexamethasone. Um Yeah. Ok. I would also say this can also come up in M and M as a neurology and M SK station. So I don't think you can escape it if it doesn't come up this year, it can also come up next year. Um ok, so 24 year old female being treated for Hodgkin's lymphoma presents the A&E with vomiting and fatigue. So this is more vague. Um but they have lymphoma. So what are you thinking about if any? No? Mhm Anyone. It's to be fair if you don't know. Think about what oncology emergencies we haven't done yet. So, we've done M SCC. We've done, uh, I forgot what we did. So, the M SCC, we did neutropenic sepsis. So, what's left? You've got hypercalcemia, tumor lysis and S PCO. Yeah. Yeah, exactly. Tumor lysis syndrome. Um, so it's purposely vague because the symptoms would be quite vague. Um, yeah. But, uh, uh, I'll go on to, uh, next one. Ok. So, tumor lysis syndrome, what is it? It's when you get a rapid breakdown of your cancer cells and your cancer cells just release loads of their cellular content, including all of your ions that are in your cells. So I like to think of cells as a salty banana. Um So bananas are high in potassium inside the cell, you but lots of potassium and then the outside of the cell is sodium mainly and then other ions. Um So that's why if you release the the inside cell content, intracellular content, you get high potassium in the blood, you get high phosphate in the blood and low calcium. So calcium and phosphate sort of go hand in hand. Um various physi physiological reasons but like very, probably not that accurate. But I think of it as if phosphate goes up, calcium typically goes down and vice versa. Um Yeah, cause they bind to each other as well if you think about bone. Um So yeah, so high phosphate, high potassium, high uric acid as well, which comes from the breakdown of the proteins inside your cells. Um and low calcium. Yeah. So risk factors. Any recent chemotherapy, the reason your cells are rapidly breaking down is because of chemotherapy. So there are certain risk factors um which I can't remember for patients with tumor lysis syndrome. Um So before you give chemo, um um for some patients, you would do a risk assessment for tumor lysis syndrome. And for some patients, you can give prophylactic medications as well. So if you're higher risk, then you would give medications to prevent. So, um, the high uric acid, you give medications to prevent that. Um, yeah, otherwise you just monitor it as well. Uh, so yeah, hematological cancers, um, are high risk for tumor lysis syndrome. Um, just because of the nature of the cancer cells, I think. Um, and typically your like lymphomas especially and your other hematological cancers. Um, typically you treat them with chemotherapy as well anyway. Ok. So presentations can be really vague if you think about these electrolytes. Um, if you got an imbalance in any of these individually, you can get those symptoms in tumor lysis. So typically nausea, vomiting, diarrhea is gonna be common muscle cramps, lethargy, pain in the joints. Um, the most important thing about any of these emergencies is a history of cancer. If you see history of cancer, you're a, you're automatically thinking about any of these, um, oncology emergencies and then your investigations will point you in the right direction. Um Yeah. So any signs of hypercalcemia, et cetera, et cetera. Um Yeah. Ok. Investigations would be blood results for all of these ions and such. So, serum uric acid phosphate, potassium calcium, you'd also do an E CG. Why do you think you might do an E CG in this case? Yeah. Good. So, hyperal uh the uh I can't, I can talk hyperkalemia. Yeah, exactly. So all of your electrolyte abnormalities can have an impact on the heart, especially high potassium and low calcium as you said. Um So yeah, so hyperkalemia management, remember you bought three categories of it. So, I mean, not, not as important here but like to link it to other learnings. So three categories of hyperkalaemia management, high potassium. You've got heart like cardiac stabilization is calcium gluconate. Second category is um shifting intracellular shifting of potassium. So that is IV insulin with dextrose always give it with dextrose. Otherwise you'll induce hypoglycemia. Um and nebulized salbutamol as well will shift potassium into the cells and out with the blood. And then the last category of management is removal from the body of potassium. So either with drugs or by dialysis. So, dialysis, if it gets really bad. Um Otherwise furosemide is one way to get rid of potassium. Um and calcium resonium as well. Yeah. OK. Cool. Uh management fluids. Yeah. So yes, you've got these electrolyte abnormalities, treat it as much as you can with fluids. So you might need aggressive fluid resuscitation to stabilize the patient. Um and then you would manage the uric acid with allopurinol, which you might recognize from gout management and rasburicase as well, which is also um for hyperuricemia monitor the patient always again, escalate care um if needed. And then you might want to consider potassium. But I would say in your case, monitor potassium. If it's still high after fluids, then you might consider salbutamol IV, insulin, et cetera, et cetera. But yeah, usually fluids will do the job at flushing everything out of your system, getting your kidneys up and working again. Um Yeah, the tumor lysis. Oh OK. I'll be really quick. So try to finish in the next 5, 10 minutes. Um 78 year old female with lung cancer presents with abdominal pain, constipation and reduced urine output. What are you thinking about here? Yeah, good. Um So hypercalcemia of malignancy. So when you have, as the name suggests, high calcium due to malignant processes, so it's a very multifactorial thing. The most important thing you're considering as a cause of hypercalcemia of malignancy is bone metastases. So there are certain cancers that have a higher risk of bone mets. Um Most important one is gonna be prostate cancer, breast cancer, et cetera. So the most, two most common cancers in males and females. Um Yeah. So other things that cause hypercalcemia. So there's a paraneoplastic syndrome as well in lung cancer where you've got um P th related protein um in squamous cell, lung cancer. Um Yeah, a rarer cause, but one of the causes that you might see on past me as well. So risk factors, any history of cancer, especially the ones that metastasized the bone, um known bone metastases, lymphoma as well has a high risk of hypercalcemia of malignancy. I'm not sure why don't ask me. Um, but presentation is if you think about hypercalcemia and your, I don't know, call it like mnemonic for it. So stones, bones grown, psychiatric overtones, Thrones as well. You can add so renal stones, painful bones, um abdominal grown, so you can get tummy pain, um diarrhea, things like that. Uh you might get depression as well due to hypercalcemia or like other psychiatric conditions. Um but constipation as well can can be caused by hypercalcemia. Yeah, investigations again, any electrolyte abnormality ecg um Also for all of these you might want to start with, I would do an a to e assessment of the patient. Yeah. So start from the bedside and then work your way up, but then obviously include the important management of each of these. So IV fluid. Oh sorry, I was on investigations. So, ecg um and then serum calcium and phosphate. So again, calcium and phosphate go hand in hand. Um You might later not, not immediate management, but you might consider chest X ray later down the line. You wanna see how hydrated the patient is because it can affect your kidneys as well. So you would do use and es uh and do a hydration status examination. So, mainstay of management IV fluids as well. So again, electrolyte abnormalities usually pump them full of aggressive uh fluid resource and it usually like does the job um and it will correct the abnormalities without any specific like management. Yeah, but otherwise you might need later down the line IV bisphosphonates the NOS the NOZ as well, which is used to treat bone metastases. Um And for the calcium phosphate and treatment of your underlying malignancy is your definitive management as well. But yeah, but the main thing is you're trying to stabilize the patient. Um So fluids a to e anything that comes up there monitoring escalate care for all of these. Ok. Last one is 68 year old male with a 60 pack year history, smoking history. Uh They're in A&E with sudden onset shortness of breath, chest pain and cough. Yeah. What are you thinking of? And also think outside of this session, if this patient came to you, what is your first thoughts? Doesn't have to be cancer related? Like any differentials that you have for this patient? What would you think? Yeah. Good. So S VC O pe anything else? So high smoking history, shortness of breath and chest pain? Yeah, exactly. So you never want to miss an A uh a IMI A CS that it could be a question they ask you in your sbar is what are your other differentials for what's going on? Um So make sure you, you have other ideas. Yeah. Could be pneumonia, pe pneumothorax, things like that. Um Good. Yeah, but obviously in the context of oncological emergencies, this is gonna be superior vena cava, obstruction. Um Yeah. So what that is is as the name suggests, obstruction of your superior vena cava, which drains your head and your, your, your head and your upper limb, your arms. Um Yeah. So if, if that is blocked, that big vessel is blocked, if you raise your arms, um and then put them down, you end up with flushing in the face, distended, neck veins, shortness of breath because of uh blocked venous drainage and then you get this sign. So what do you call this test or this sign on the? Right? I know it's on the screen but like if you ignore that, what is this clinical sign? Mhm Yeah. Good. Uh So Pemberton's sign. Yeah. So if you get, get a patient to raise their arms for around like four minutes, um, and then you would get all those signs, as I said, yeah. So risk factors is known lung cancer or any, any suspicious history that they could have underlying lung cancer such as a heavy smoking history, um, lymphoma as well. So any central, um, central lung, uh, no, no central cancers can cause SVC. So lymphomas in the neck, um, small cell lung cancer because it's more central, yeah, or any cancer that can cause nets as well. Um, yeah, so presentation is shortness of breath, pemberton sign, um, cough, any of the cancer signs, chest pain as well. Um, yeah. So, investigations again, you would say I would do an, a three assessment of this patient. Um, clinical examination bloods at this point, you probably won't do bloods. Um, you might go straight into um a chest X ray as well because you wanna look at the, the tumor, chest ct would take a bit longer. But yeah. Um but those are things you can suggest in your recommendations. So I'd like to do a chest X. I've done a chest X ray. I'd like to do a chest CT to look for this, this and that um management. Again, high dose dexamethasone. So you'll notice a trend. Um dexamethasone is very strong, steroid, very strong, uh immunosuppressing um and uh reducing inflammation. So, again, the same concept as M SCC reduces the inflammation around the tumor to reduce the size to bridge the gap between you and definitive management. Yeah. So if they are very short of breath, so in your sbar, if they're suddenly like unconscious, now, you're very concerned because they probably can't breathe. Um So you need to secure the airway escalate if needed, you might wanna bleed the anesthetist. Um If not give, you would say I would want to give I uh high dose dexamethasone. Um and consider the patient for radiotherapy to shrink the tumor. Um You might also later down the line, consider a stent through your superior vena cava to keep it open, but definitive management is to get rid of that tumor. Um So that's SPC, so those are your oncological emergencies? Any questions at all for those? Um Yeah, I think in Manchester they're covered quite well in your TCD S. So I don't wanna go through it in a lot of detail. Ok. Um So last thing I'll go through is just a quick run through on the ethics stations. So obviously when it comes to cancer, um empathy is really important. You have a lot of stressful situations, um A lot of concerned um relatives as well. So again, uh you know, again in my, so I had, so I had nutri sepsis as data interpretation. I also had an ethics station on um like confidentiality, but a very common ethics station also for the breast um specialty is your two week weight pathway which we'll go through. Oh, by the way, I didn't mention this at the beginning, but if you don't know anything. So if you're from Manchester and you don't know anything about your Aussies, so obviously, you've got F and C AY which are summit and your M and M later down, um which are also summit. The general rule of thumb is per week of placement on that specialty. You have one OSK station. So you've got one week on oncology. You will have one OS station on oncology. You have one week of breast. You also have one station on breast and they, they go hand in hand to breast and oncology. Um You got four weeks of say, um GP, you have four GP stations. GP can also include the two-week wait pathway. I also had two week weight pathway for bladder cancer. So that was a GP station, not oncology. So again, um it's not a hard and fast rule. There's a lot of overlap in these. Um But yeah, so two week wait pathway in terms of how to approach it, it is an Ethics station um slash difficult communication station. So you'll get one of those per ay. Um Yeah, it's usually one Ethics Station still for like in year 34 and five. I think I'm not sure about five but year three and four, typically one Ethics Station. Um Yeah, but they might have other explanation stations which have a bit of difficulty. Um ok, so two week wait pathway, I will say in F and ci found that there was a lot of hybrid stations as well. So unlike third year where it's a full explanation or full history, you might get, take a history from the patient and then explain the next steps. That is a hybrid station. So you need to manage your time. Well, because the examiner is not gonna move you on. So four minute history, four minute explanation. Um their history will, if it's hybrid, their history will be quick, meaning they will say no to a lot of things that is a hint to move on. Yeah, because it's not in the script if they say no, not in the script. Yeah. Um Yeah, I would say read the prompt really carefully as well. Um Because otherwise you might miss that. It's a hybrid station and you might just focus on the history. Um But it was very common. It might also say something like take a history and answer their questions that might also be a hybrid station as well. Um Yeah, so two week wait pathway. Um So take a history and explain the next steps. It's usually quite obvious. So I had bladder cancer. It was painless hematuria. So send them off for a two week wait pathway. Uh And I need to explain it. So the way the station goes is they've got some like red flags in their history for a two week wait referral. Um So I would say something like, ok, so based on what you've told me today, um there are many things that can cause your symptoms, however, one of the rarer causes but more serious that we wanna rule out is cancer. Therefore, we wanna refer you on what we call the two week weight pathway stop ice. Have you heard of this before? Do you know what involves? Is there anything that worries you right now? You know, and then explain it. So remember your structure for any explanation, brief history, understanding concerns, explanation, summary. Yeah, do the same for two week weight pathway. But obviously you need to know what the two week weight pathway involves. It's the same for most things. So you'd say it's a referral to the specialist doctors um who know a lot more about these cancers, they'll do some tests. Um And they are trying to rule out cancer. It doesn't mean that you have cancer, but we want to rule it out to make sure that you don't. Um And if you do, it means that we can intervene quickly. Um That's why we want to do it within the next few weeks. Um Yeah, so a lot of this station is gonna be about empathy and dealing with difficult emotions. Guarantee the pa the simulated patient is gonna be like, well, I wasn't really expecting that today. Um So in year four, you also learn about spikes where you do breaking bad news. Um Also really important to add elements of spikes to the two-week Great pathway, which is just a lot of empathy um and just pausing as well. So it's OK to pause even if you're stressed that you're running out of time. So lots of empathy, lots of eyes um but make sure you get the explanation in. So it involves this for the breast, two week weight pathway triple assessment. You've got clinical examination, biopsy. Um and then your what is your one biopsy? Examination and history? Yeah. Um so yeah, so two week r pathway. Um you have to be honest, you are looking for cancer but be reassured doesn't mean you have cancer. Yeah, but do not give false reassurance. It's not like you definitely don't have cancer. Um yeah, you need to find a balance in that. OK? And last one again, I put this in because I had it last year. But confidentiality like you had in third year, remember the rules of confidentiality? It's typically um can't give information about someone else. Um So this scenario, someone comes into the GP they're concerned about their wife. They've been put on what they call a two week wait pathway, but they don't know anything about it. They want to speak to you to find out what's going on the principles of this station as you had in third year, you encourage them to speak to their relative um about it cause you can't give them the information. You're bound by law. It's your duty, it's your responsibilities to them. Lots of ice, lots of empathy can understand it's difficult however, I can't give you more. Um And then offer a solution as well to any ethics stations. Um What do you think if we brought in your wife and then we talk together about this is that something that you think. Yeah, so bring it on them as well. Um To agree on a solution, time management is important. Don't break confidentiality. You will fail the station if you break confidentiality. Um and be empathetic as well. So, yeah. Ok. And that's it pretty much sorry. I run over a little bit. Um So next is the a practice which again, I highly encourage you to do because they link in very, very well to this session. Um It's 33 stations, two SAS and then 12 week wait referral highly recommend practicing it very, very common stations in all specialties. Um Yeah, yeah, you can explain two week wait referral. That's fine. Uh You just can't give patient sensitive information. Um Yeah, so just your generic rules of confidentiality. But again, what's most important is ask what they're concerned about, do lots of advice. Um Yeah. Um anyone else have any questions otherwise I think. Um Yeah, if you want. Yeah. Um Patricia, um one of the ay facilitators, um isn't going to make it. He's told me that just, I, well, I sort of chased him down now and he's told me he won't be here. Um He has for whatever reason. Um But then another one I've not heard from. Um So I'll just see if the events team can chase him down. If not, there's currently one person in the room. So how many people stay? That's fine. I think typically not, not everyone stays for. Um But if I'd say if anyone here does want to stay for Osteopro, which again, I recommend because we wrote the stations. It's not anything you'll find anywhere else. So it's very specific to Manchester. So I would say join the Osteopro if you can. Um Yeah. Oh yeah, if it's too much is now as well. So yeah, we've got 22 breakout rooms. So. Ok, that's good. Um So yeah, I think I'm not how you guys usually run it, join any breakout room. Uh I usually, once they're in um once everyone's like uh once all the speakers are in, I'll just go down the list um for the people who are still here and tell them to go to which room split them in half. Yeah. Yeah. Um So uh for the people who are, are, are you, are you finished Patricia? Yeah. Yeah, I'm done. Ok, thank you. Um I'll put, I need to put the feedback form in now. Yeah, I just sent it. Um Yeah, but yeah, I'll stay to answer any questions if anyone has any, but please do join the breakout rooms to, to join the um breakout rooms. You should be, you should be able to see them available um just as open breakout rooms. Er Isaac, I can see you're in this room. Um You can, there's a breakout room made for you if you just join that and then we'll send the students in Denise is already in hers. So there's two rooms, one for Isaac, one for Denise. So I'll just go down the list and sort of late um allocate you. So um Ashok Anastasia Anita Farina Gift and Joseph, er if you're staying, you can all go to Denise's room. So that's Astral, Anastasia Anita Farina and Gift and then everyone else uh can go to Isaac's room. So just click on the breakout room. It's either Denise or Isaac. Um So yeah, of diabetes the same time. So um we all the diaphragm um and doctor to scar just to check the people who are still in here. Are you having issues getting into your breakout room or are you asking questions or are you not present? Um Just to say again, you're free to join the breakout rooms when you're ready. I'll just say the allocations again in case people have missed it. But um Ashok, Anastasia Anita and Farina can all join Denise's room and then everyone else can join Isaac's room to see doctor. I Yeah, my, you know, both of this. So no side. Yeah, I think Anita, that is a tricky question. It's something that II was a bit stuck on as well in that station. Um In terms of like how much they actually know about the about what's going on. Um Yeah, I think you can mention what the pathway is about but not like it's, it's tricky because you have to find a balance between, do they, if they know it's related to cancer? Um, you can just sort of try and stay away from the, the conversation but just say, um, yes, it's this. Um, so I can't give you any more information about your wife's condition and yeah, I would encourage you to speak to them. Um, however I can reassure you that your wife is getting the care that she needs. Um, and the doctors are doing what they think is in the best interest of them or what's best for them. Yeah. It's a lot of like dilly dallying around the subject, um, in the, in these stations I'd say. Yeah, you can't confirm that they've been sent on the pathway because you think they have cancer because you don't know that as well. Um, you're not the doctor. That's all the thing. Um, some bones, all the exams. Yeah. Ok. Any other questions? Otherwise I think I'll leave it there and then if you fill in the feedback form you'll get the slides. Which is very your one? Cool. Are you happy with that? Am I ok to go? Yeah, thanks, Patricia. Right. Thanks so much. Bye. Take care. Bye.