Accident & Emergency Medicine: Triage, Anatomy, and ABCDE Assessment

Hi everyone. How you all doing? Uh, type in the chat if you can see my screen and if you can see me.

Hello. Awesome. How you all doing? Okay, perfect. Where's everyone uh tuning in from today?

Oh my god, the chat is going nuts. Okay, cool. Perfect. So, we have people from all over the world. Um,

what year is everyone in? Like what school year yet are you guys applying to? Medical school or um thinking about

applying. Okay. Wow. So, the numbers are moving very quickly, but I can see most people

are basically from year 9 to year 12. That's awesome. Okay, cool. We'll start in a few

minutes. Um, so we'll I'll leave the chat open for now. If you guys have any questions from today, then please post

them in the Q&A. Uh, there's a Q&A section as well on Zoom, but try not to um, spam the Q&A section cuz then I

won't be able to see your questions. And also, you can upvote each other's questions. Um, so then if you see like a

question that you like that you want answered, then please upvote it. Uh, so that's that. Awesome.

Yeah, the chat's going nuts. Okay, so I think let's jump right in. So today's session is going to be about um 2 hours

long. Uh but we'll take a break in between um and then I'll leave some space for Q&A as well. Um but yeah, so

in these sessions essentially what we'll do is we'll go through some medical cases together and then the idea is to

get you to think about what it's like to be a doctor. You don't need to know any of the stuff that we're covering. Um I

don't assume you guys would know any of the stuff that we're covering. So don't worry if some of the stuff seems a bit

difficult to understand. Um but the idea is just to gauge your interest. So don't worry if certainly at your stage I had

no idea what was going on. Okay? So don't worry if some of the concepts are a bit too difficult. And there are some

sections by the way I'm assuring you that we'll be covering operations and stuff. Uh and so they might be a little

bit intense. They might be a little bit gory. So I'll I'll let you know when those sections come up and you can

choose to watch them or you can choose not to as well. Okay, cool. So let's lock in. Let's um move into the session.

So this is me. Uh my name is Asama. I've been a doctor uh for a while now. I graduated from Imperial College London

and I did my training in radiology. Um and then I moved to work in the pharma industry, but I did some A&E rotations

and I loved working in A&E. So today's session we're going to um use Menty. So if you don't mind logging into this, so

use a QR code or you can use this code as well. Um and yeah, so if you log in to menty then some of the questions will

be on there. Yeah, you can write notes as well. Sorry, someone said it's lagging. Is

that right? Is is everyone experiencing some lag? Because I feel like No. Okay, fair. That's good.

Okay, someone said there's an echo. Yeah, I don't know about an echo. Is there an echo? Can you guys hear an

echo? Can you guys hear me well? Okay, good. Excellent. Okay, so what if you guys uh sign into the menty

also let me know if the chat um gets a bit distracting because I can mute it. But I think you should be able to um

minimize it cuz I think having the chat open is also important. And also if you want to ask any questions, you can also

raise your hand and then I can unmute you and we can talk like that. Uh so someone's just said I can't hear

at all. Um so maybe that's an audio thing. Do you want to log out and log back in? I guess he can't hear me, so he

wouldn't be able to know what I'm saying. Can you Can everyone hear me? Let's write in the chat. Yes, W's in the

chat if you hear me. Okay, perfect. So, you can hear me. Excellent. Okay, so let's jump in. Let's

start the session. So, today's session is about accident and emergency. So basically we're going to talk about how

an emergency department is is is run and essentially um this is how medicine works kind of all

over the place all over the world. So for example in at the end of medical school we had to do a rotation um abroad

called our elective and I did mine in Malaysia and I had to work in the Malaysian emergency department and that

was very much similar to how the NHS is run in the UK. So the way an emergency department is run is basically there's

this um concept of triage where you triage who are the most unwell patients and you the idea is to see them before

the more well patients. So there's two ways that the patients come into the emergency department. First of all they

can come in through uh an ambulance. This could be like a a vehicle or could be like a helicopter ambulance or some

patients would just walk into the emergency department. Uh and then they would get triaged and

then there's three kind of different sections of an emergency department. So there's the resource section, there's

the major section and there's the minor section. Type in the chat which section do you guys think the most unwell

patients go? Where do they go? The most unwell. Yeah, well done. So, most unwell patients go to resource and and

generally speaking, the most well patients go to minors. Um, basically the idea is resource patients are ones that

require intervention right away, otherwise they're at the risk of death. Majors is where patients come that are

going to be admitted to hospital. And minors is where injuries that can be treated in a in the emergency department

and then you can probably send them home. So, for example, um someone who's come in with a fracture,

like a broken arm, that could be quite serious, but you can put the arm in a cast and then you can send the patient

home. Does that make sense? By the way, I think I'm going to mute the chat now and I'll unmute it periodically uh cuz I

think some people are getting distracted. So, let me mute the chat and

chat. Oh, here we go. Okay, the chat will be muted now. So,

there you go. Mute. Okay, perfect. So, this is how an emergency department is generally split up. Okay, so there's

there's resource, there's majors, there's minors. uh but the most important concept is a concept of

triage. So triage is the action of sorting out um accident emergency attendees according to the severity of

their illness and basically this determines in which order they are seen. Okay, so that's the

concept. So let's practice some triage together. So this is actually quite a difficult um

example but let's see if you guys can solve this case and then by the end of today you should be able to answer this

question. Okay. So triage these patients in order of the ones you want to see first. What do you guys think?

What's the most serious in your opinion and what's the least serious? Okay, I'll wait for more votes in. Uh,

let's have a look. So, we have 73 Q&A questions. That's crazy. Okay, let's see. Uh,

let me filter some through some of these. Okay, cool. So, I think most people have

voted now. So, let's have a look how you guys voted. So, uh triage patients, patients come in with symptoms of a

heart attack. Okay, I agree that's quite serious. Uh but that's probably not the first one you'd see. Patient comes in

struggling to breathe. So that's very serious because if your airway is compromised then you can die within

minutes. So that's very serious. So this probably this patient will probably come first. Patient comes in with weakness in

his arm. Okay. So what do you guys think that could be? Uh type in the chat what do you guys think? If someone comes in

with weakness in arm, what's the worst thing it could be? Yeah, perhaps it could be a stroke. Right. Okay. Which is

by the way very similar to heart attack. Heart attack is when the heart muscle doesn't get enough blood supply. A

stroke is when the brain doesn't get enough blood supply. Okay, so they're very similar.

Uh and then patient comes in with a skin rash. That's right. That that's probably the least worrying. However, there is a

condition where having a skin rash could be very serious. Does anyone know when having a skin rash could be like really

serious? Okay, people saying menitis that's good. Yeah, that could be quite serious. But

what could be like life-threatening right away? I'm thinking along the lines of like say

someone at some peanuts and they were allergic allergy. Uh anyone know what we call

that when someone gets gets really severe allergy? Anoflaxis. Yeah, well done. You guys are very good. Well done.

Excellent. Okay, back to muting the chat. So anoflaxis is a very serious allergic reaction. And by the way, the

reason why it's very serious is because you will have a skin rash, but also your airways will get blocked up uh and you

will struggle to breathe and then you you basically die from suffocation. So that that's why an anaphylaxis is very

serious, okay? Because it compromises your airways. So we'll we'll talk about this um

triaging example later on and I'll then by the end of today you'll you'll be able to know why they're ranked in this

way. So the way I would rank them is first of all you'd have the patient struggling to breathe then the heart

attack patient then the patient with weakness in the arm then the skin rash patient. Okay that's how I would rank

them and at the end of the session we'll talk about how how we do that. So now let's talk about something else. So what

are the vital signs? Anyone know what the vital signs are? These are things that we measure that um

yeah well done. Blood pressure is one of them. Excellent. What else? The pulse. Excellent. Oxygen saturations. Very

good. And there's a couple more. Temperature. Very good. And there's one more. Breathing rate. Excellent. So I

think you got them all. Very well done. So these are the vital signs. Okay. Okay, the vital signs are very important

because they allow us to track patients and these are specific for the patient. Okay, like for example, some patients

might have a really high heart rate just normally and some patients might have a very low heart rate. Um, so by the way,

anyone know why someone might have a really low heart rate? Why would someone Yeah. So generally

athletes will will have a a low resting heart rate because their heart muscle is so efficient it only needs to pump a

certain number of times. Um anyone know what other common reason why your heart rate might go down.

Sleeping. Yeah. Well done. Yeah. So that's a common reason. Actually there was uh an incident once where um I was

working in hospital and um one of the like nurse students was measuring um like was doing vitals for a patient and

it was overnight and basically she tried to feel this patient's pulse and wasn't like she couldn't feel a pulse. So she

thought his heart rate was like completely she she thought he was in cardiac arrest. So then we put the

emergency buzzer out. We all came in and then the patient was basically asleep. We woke him up and he was like why is

everyone gathered around me? Um yeah that's what we call a code. So it was it was a strange scenario but because the

patient was like in deep sleep and I think the nurse didn't want to like disturb him so much and she couldn't

feel his pulse. kind of crazy but anyway these things happen. So respirator rate is the other vital sign. Then you have

oxygen saturations, blood pressure and temperature and each one has like normal uh parameters. So for example heart rate

should be between 60 and 100. Respiratory rate between 12 and 20 is is normal. Oxygen saturations above 94%.

blood pressure there's like an ideal blood pressure which is basically the textbook blood

pressure 120 over 80 but it varies and then temperature uh basically anything below 37.5

um so this session will be about 2 hours long I think someone was asking in the chat uh and we'll take a break at the

mid midway point and then we'll have Q&A at the end as well cool so now let's move on to resource So

resource is where emergencies happen. So this is with for all the trauma calls for all the serious trauma. So for

example, if someone's been involved in a major car accident, they'll go there. Um and also where patients who have gone to

majors but they get more unwell, they end up going to resource. So majors is where most patients go and these are the

patients that basically you see in emergency department and they're going to be admitted. So, say someone comes in

with a symptoms of a heart attack, they'll go to major. Someone comes in with a chest infection, they'll go to

major. Someone comes in with um renal collic. Anyone know what renal collic is? Let's see in the chat. Anyone know

what renal collic is? So, renal collic to do with the kidneys. Yes. Excellent. So, renal collic is

basically uh kidney stones. Um, so it's when you have kidney cells and it's meant to be one of the most painful

conditions you can uh ever have. Uh, actually in medical school I actually thought I had this um and

because we were studying like like about the kidneys and how they work and stuff and I I got a bit paranoid. I was like,

"Okay, I've got this little pain in in the in the in the area." And basically what happened was the day like during

the day I um basically fell over in the shower and then after I went to sleep I woke up I was like oh there's pain in

this like in the kidney region the loin region and I was like oh my god I've got kidney stones. So I went to the

emergency department and then I told the nurse I'm a medical student and that I think I've got kidney stones and I they

made me go to the front of the queue straight to the front. Uh and basically turned out I didn't have anything

serious. So but it's one of those things in medical school um when you read about different diseases you you might you

start to think okay do do maybe I've got this and you get a bit paranoid and it happens very frequently actually a lot

of medical students suffer from this. It's called um medical school syndrome. Uh Nana's asking, "Am I muted?" Yes,

don't worry, you're not on on um on camera or on on on um audio. I can't see you guys.

Uh so yeah, so that's emergencies. So let's move on. So now this is how we categorize any

sort of emergency and access emergency department. It's called Dr. ABCD. And basically the idea is that we want to

solve the things that are more serious first and then move on to less serious things. So for example your airways

being blocked that's very serious. You can die within minutes and therefore we need to unblock the airway and then

after that comes breathing then circulation then disability then then E which is everything else and DR just

stands for um danger and response. So the principles are we assess in in the order of urgency. Airway problems will

kill you before breathing before circulation. If there's a problem investigate andor try doing something to

fix it before moving on and once you finished the AT assessment go back and reassess what we did previously. So the

first two D and R. So first thing you should check is for danger. This doesn't really apply in a hospital setting, but

for example, say you're going to help someone who's been involved in a major car accident on a motorway. You have to

be careful that when you go and help them, you don't go into oncoming traffic, for example. Does that make

sense? So, you have to make sure that it is safe for you to approach. And then response is, can the patient respond?

So, what level of response does they have? So, we have different ways of ranking this. We have the AFU score. So

the A is for alert which is the highest level response then verbal stimuli then painful stimuli then unresponsive.

Okay, those are the categories. We also can use the Glasggo coma scale which is another way of saying the response

level. So this actually uses three different parameters. Do your eyes open? Are you talking? And are you able to

move your body? Okay, so this is um the glazoma scan. It's out of 15. And very uh strangely, this score, the lowest

score you can get is three. Three is like game over, whereas 15 is like you're you're good. Um so it's weird

that the score doesn't start at zero. It starts at one or three. Okay. Um but you see you basically assessing three

different categories. Eyes, u verbal, and then movement. Okay. So this is this is a a quick thing you do when you see a

patient that's that you're assessing. You quickly do the the either APU score or the G gcs score.

Um yeah so that's that. Uh so then we move on to ABCD. Okay. So before we move on

to um what airways is, let me show you guys what the airway actually is. Okay. So let's have a look. So now you should

be able to see Bob on your screen. Bob, our anatomy model. Can you guys see that? Let me open the chat. See if you

guys can see him. Bob, can you guys see Bob? Okay, excellent.

Okay, so this is Bob, our anatomy model. And essentially, we're looking at the

airways here. Okay, so the airways are basically one of your most vital structures because they allow uh air to

get into your lungs and then through that process you're able to do gas exchange and then get oxygen into your

bloodstream and then be able to transmit oxygen to the heart and then to the whole body as well. So it's very

important. Okay, if the airway is blocked, you can die within minutes. So it's always important to make sure the

airways are open. Okay. Uh, excellent. Well, I'm glad you guys like Bob. Bob Handsome Bob chat. I don't take

any bad chat about Bob at all. Anyone who talks bad about Bob gets kicked out. No,

I'm joking. But anyway, Bob is goated. Yes. So, um, this is the airway. So the airways are

basically your your nose and mouth. This area here is called let me actually remove the skull

for a sec so you can see it. So this area here this is called uh this is your

nose. This is called the nasoparings and this is called your oral cavity your oro fairings. Okay. So these two areas this

is basically your fairings. These are connected. So that's why you can breathe through your mouth and you can breathe

through your nose as well. Okay? Because air will go down to the fings to then this area here called your larynx and

then from your larynx you'll go into your windpipe. Anyone know by the way what's the fancy

term for the windpipe? There's an anatomical term for this. Anyone know what the wind pipe is called? Yeah. Oh

god. You guys are very good. Okay. So it's called the trachea. Excellent. Very well done. So, the trachea is your

windpipe. And you can see the trachea, what's so special about the trachea is that it's got these C-shaped rings.

These are cartilage rings, like very tough. And this means that the trachea is always open. Okay. Now, there's a

structure that goes behind the trachea. That's this kind of smooth muscle here. Anyone know what structure sits right

behind the trachea? What structure is that? The esophagus. Excellent. Yes. So, so your food pipe

sits right behind This is your esophagus. This is your trachea. Your food pipe sits right behind um your your

trachea. And basically this means that if you um swallow any food, what happens is you have a structure here called the

epiglotus, which basically closes the airway up. So then food goes down to your esophagus. Okay. So swallowing is

actually very coordinated activity. Okay. To swallow you actually need to have very good control um over your

neuromuscular bundle. So So what happens is when you swallow food the epiglotus closes the

trachea and then food goes down the esophagus. Okay? The esophagus can collapse. Okay? It doesn't have the she

C-shaped rings that keeps the trachea open all the time. Does that make sense? So your trachea needs to be always open.

It's a vital structure. Okay. Then as I go down um I'll remove the heart for a second. The trachea then splits into

two. Okay. So there's you have the right main bronchus and the left main broncus. Okay. And basically what happens is each

then takes air to the lungs. Okay. Um now what's important to know as well is that actually the lungs are slightly

different. Okay. So you have the right lung and the left lung. Anyone know? Type in the chat which lung is bigger,

left or right? Type in the chat. Okay. Excellent. So most people are saying right lung. So you're right. The

right lung is bigger than the left lung. Anyone know why the left lung is smaller?

It's got a massive organ indenting into it. Anyone know the heart? Yeah. Excellent. Perfect. Right. Go back to

mute. So the heart sits more on the left hand side and it's it sits there. So um the right lung is bigger than the left

lung. Okay. Uh and you can see here actually the right lung. Can you guys see this line here? This is called a

fissure. You can see that the right lung is actually split into three different loes. Okay. This is one lobe. This is

another lobe. This is another lobe. You have the upper lobe, middle lobe and lower lobe, okay, of the right lung. Can

you guys see that? Three loes. Whereas the left lung is only split into two loes. So you have the upper lobe of the

left lung and the lower lobe. Okay. Um and basically these loes basically act like mini lungs. they they have

independent airway supply, blood supply and basically they they function as like independent mini lungs. Okay. Uh and

this the divider here is called a fissure. Okay. We you don't need to necessarily

memorize these anatomical terms because you'll learn this in medical school but it's it's called a fisher. Okay. But

anyway, your airways back to airways. Airways is basically your nose, mouth. This area is called the fins. This goes

into your larynx which is your voice box then into your trachea. Okay. And this is why when we assess for airway if

someone is able to talk that means they're able to move air through their larynx. So what

does that mean about their airway? If someone is able to talk, does it mean their airway is open or closed?

It's open. Excellent. Well done. So that's what um it means. Okay. So that's one of the things you assess for by the

way. Uh yeah. So the so this session is recorded by the way. So yeah, you can

catch up with it later as well if you want to. Yeah. The larynx is your voice box. Yes.

Cool. So let's move on uh to back to the uh presentation. Oh, can you guys see that?

So, basically just to recap, uh you have your fings go to larynx, trachea splits into two and then divides into uh

bronchioles, internal bronad, then alvoli where where gas exchange happens and that's the function of the lungs.

Okay. And by the way, to get air into your lungs, there's a really important muscle that's a dome-shaped muscle that

basically um changes how much pressure is in in your thorax and this is called your diaphragm. Very important muscle.

Okay. It's the most important muscle of your breathing which we'll tackle in the next bit. So airway the way to assess

airway is first of all is the patient talking? If the patient is talking then that means the airway is probably open.

Okay, because to generate voice you need to have an open airway. Is there anything blocking the airway? Um is

there any chest movement or noises? So if someone if their chest is moving that insulates air is getting into their

chest. Okay. So that that means the airway might be open. And then you also look out for signs like for example

sinosis. If someone's airway is closed, um they might turn u slightly a shade of blue which indicates airway might be clo

might be closed if they're choking basically. Now question for for you guys is how do

we keep the airways open? Anyone know of certain maneuvers that we can keep the airways open with?

Right. Wow. So there's a lot of um different suggestions. Very good. So I think you said it in the chat. So

there's different ways we can keep the airways open. So first of all, some non-invasive things. So for example, you

can do an activity called the jaw thrust or head tilt chin lift. So, this is an example of the the head tilt chin lift.

Now, you have to be careful sometimes um because you don't really want to be doing this if someone's involved in a

very big car accident, for example. Anyone know why? Why would you not want to do this in someone who you suspect

might have a very severe injury? Uh anyone know why you don't want to be moving around their spine?

Let's have a look at the chat. Wow. 98. Yeah. So, spinal injury. So, when you suspect a fracture of the C-spine, so

that's the uh spine in your uh the vertebrae in your neck, then you you have to be very careful of doing um a a

head tilt chin lift because then you might actually make it worse. The fracture make it worse. You want to

stabilize the spine. Okay? So, that that's when you don't want to be doing a head chin. the jaw thrust might work

better. Then you can go into more invasive things. So for example, this is called a gadell or orangial airway. You

can put this in and it allows you to kind of keep the airway open and then the most invasive step is some something

called incubation where you basically put in a tube into their trachea and you inflate that tube so it stays there and

then you can then supply oxygen through that tube. Does that make sense? So this is the most invasive way. By the way,

anyone know why you can't do this on everyone? So say someone is awake and talking and you try and put a tube down

their mouth. What do you Why would can you not do that to someone like that? This only really has can be done to

people who are unconscious. Yeah. Excellent. Because you have a gag reflex. So if someone's conscious,

they'll they'll gag this up. So basically, you have to sedate them to be able to do this. Or if they're

unconscious anyway, then you can do that. Okay. So, by the way, you guys know so much. I'm very impressed. So,

well done. You guys seem to be very knowledgeable, which is excellent. Okay, cool. So,

let's move on now. So, then we've assessed airways. We think they're open. Then we move on to breathing. So, B is

for breathing. So, let's go back to our anatomy model and discuss uh breathing. So, here's Bob. Back to Bob.

So breathing is done um it's the process of basically gas exchange and it's done in the lungs. Now remember the most

important um muscle of breathing is this muscle here. This dome-shaped muscle. Anyone remember what it was called?

The diaphragm. Yes. Excellent. Well done. Okay. So that's called the diaphragm. Let me mute the chat. Back to

mute. Okay. So the diaphragm is one of the most important muscles in in breathing. Uh and actually when you're

breathing normally like when you're not say doing exercise then it's pretty much the only muscle that's required for

breathing because this controls how much air gets into the lungs. Now when you exert yourself when you are doing

exercise then you might use other muscles as well. So, you might start to use your intercostal muscles. You might

start to use your traps. And actually, that's actually a good way to assess if someone uh has problems with their

breathing because if they if you see someone that's exerting themselves breathing,

then um you'll be able to tell because they're using other muscles. In fact, let me show you guys a video uh of how

we assess someone's breathing. So let's see if this works. Let me know one

when you can see it. Okay. So I want to show you guys um right.

So this is uh a video. Let me see if you can see it. Okay, let's see. I'll open the chat.

[sighs] Can you guys see my screen right now? Okay, so this is a video of a child who

has um trouble breathing. Okay. So, so what do you guys notice? Type in the

chat what you notice. Yeah, exactly. So, he's using his abdominal muscles, chest. Yeah, exactly.

So, so in general when when you're breathing normally, when you don't have any problem breathing, um

you don't you don't um you only use your diaphragm basically. But then when you are struggling to breathe, then you try

and use other muscles to help you get in as much air as possible into your lungs. Okay? So that's why you see this. So

these are very subtle signs that you can pick up by the way. Um okay, let me mute the chat again. The chat is going bit

wild right now. Um so yeah, so that's so that's one of the

subtle signs to look out for. Okay, but the diaphragm is a very important muscle. Basically that's the gist of

that and it's the most important muscle in breathing. Okay. Um, oh by can talk so much about this,

but I don't know if you guys want to know the law, but there is, by the way, some really crazy conditions where you

end up basically your diaphragm stops working. It's it's a condition where do you guys want to know about these or

not? Is it like interesting to you guys if I tell you like random conditions? because actually this condition is is so

mad that um someone that I know actually got this and they ended up being an intensive care unit for a while. Um and

actually it's very crazy. Okay, so the human body, what you have to realize is the human body is one very fine-tuned uh

system, okay? And everything has to be in balance. So there's a condition called Gileiam. Has anyone heard of GBS?

Gileiam syndrome? It's a very peculiar condition. And basically what happens is usually it follows

um a bout of food poisoning. uh like you. So my the guy that I know basically he had um some food abroad and

then he came back home and he felt really fluish and felt really sick had like diarrhea, vomiting and then

basically he started um having like weakness in his legs and then the weakness then became more severe and

then it started going up and this is what we call ascending paralysis. It's one of these conditions that's

much about it. Okay, let me mute the chat again. H so we don't understand much about it, but what happens is it's

called ascending paralysis. And basically your immune system basically I think because the immune system is

trying to tackle this um bacteria that causes the food poisoning. It then creates these um it's called mimicry. It

creates these like antibodies that then actually react to the human body and you get ascending paralysis. So the

paralysis starts off with your legs or could start off with your arms and then moves slowly up and then in some

patients it could get so bad that it moves to your diaphragm and basically when it moves to your diaphragm and and

it paralyzes your diaphragm then you can't breathe and basically you die from card respiratory arrest because not

being able to breathe. So it's very serious. Um, so this guy that I know had to be in intensive care unit for about 3

months. Uh, but luckily he made it out and he's he's kind of recovering now. He's much better now. But can you

imagine like this kind of condition where you have this paralysis moving up and then suddenly getting getting to

your diaphragm. So this is the diaphragm is one of the most important muscles is the gist. But

also just remember that um the human [clears throat] body is such a finely tuned organ. Yeah.

So this guy's fine now. But um it was such a weird condition to have. It's very peculiar. Um and it's called

Gileiam. If you guys want to read up about it, it's very interesting. You should read up about it. Gurb syndrome

GBS. Uh yeah, don't worry these kind of like deep knowledge you wouldn't it wouldn't

be in the exam. I'm just telling you guys just to gauge your interest. Like if you if you're interested about

neurology because actually it's one of the most interesting things. Uh then I'd recommend reading up about it. It's

called GBS syndrome. But can you imagine like you have food poisoning and suddenly you you're

paralyzed. Like it's kind of crazy, isn't it? But um some conditions are just very peculiar.

Cool. So let's move on now. So breathing basically the main muscle of breathing is your diaphragm. Your the idea is to

get air into your lungs. Once air is in the lungs then gas exchange happens. Now gas exchange happens at the a place

called the alvoli. Uh and basically there's a very big net of capillaries that basically will transmit oxygen into

your bloodstream uh and carbon dioxide outside and then that will then go to your heart. Okay. So that's the idea of

of of breathing. So how do we assess breathing? So let's go back to the slides and figure out how we assess

breathing. So breathing is assessed first of all by looking

uh let's see can you guys see my screen now? I think you should be able to let's see yes should be working. Cool.

So breathing how do we assess breathing? So first of all look for signs of distress or struggling to breathe. So,

this includes using other muscles. Um, I think the screen's not working. Okay, there you go. This should work. So, this

in includes using other muscles, ailary muscles, uh, your traps, your abdominal muscles, intercostal muscles. That will

be signs of strugg. Look for chest symmetry. So, the chest should be symmetrical. Movement should be

symmetrical. But if it's not symmetrical then um that could indicate that one lung is not getting any air and the

other lung is and therefore you need to assess and also you can listen to the lungs if

you have a stethoscope you can listen over the area and listen for air entry okay and you can check where the air is

going into the lungs you can also measure the respiratory rate so this should be between 12 and 20

if it's too fast that's bad that's called tachibania Yeah. And if it's too slow, that's also bad. Okay. Because

you you're basically not able to breathe enough to sustain oxygen supply to your organs. And then oxygen saturations, you

can also measure this and should be above 94%. And we use this pulse oxometer. It's it's basically an

instrument that you put on the finger and you can measure someone's oxygen saturations with that. Okay. So this is

how we do it. And then what can we do if someone has a breathing problem? Well, we can do two things. We can

administer uh oxygen through a mask to try and help if their stats are low. You can try and give them oxygen to try and

help them with their stats. And also you can then do some investigation like for example you can do a chest X-ray to look

at the lungs. So this is an example of a normal chest X-ray. Okay, let's quickly label this chest X-ray. Um,

so you should be able to see my annotation. So this here

is one of your lungs. Anyone know which lung I'm pointing at here? Let's have a look at the chat. Which lung is this?

The one that I've highlighted. The right lung. Excellent. Remember that the left lung is smaller and the heart

is more onto the left hand side. So this is uh on the other side this is the left lung here and then in between the lungs

we have in fact let me unmute so you guys could take part in this. So anyone know

what organ is here? This organ here. What organ is that? The heart.

Excellent. Well done. Anyone know? Okay, this is going to get more difficult as we go. Anyone know what

bone is this here? You see the thing with X-rays is that you shine X-ray energy through someone's

body and different organs will absorb the X-ray energy differently. Bone is very dense. It will absorb almost all

the X-ray energy. That's why it looks white on an X-ray. Whereas the lungs contain a lot of air, which is not very

dense. So, it doesn't absorb much X-ray energy. And yes, this is a clavicle. Excellent. Well done. Okay. Um, what

about this bone here? These bones here. What What bone are they?

The ribs. Excellent. Well done. How many ribs do we have? Anyone know how many ribs we have?

Yeah, 12 pairs. Yeah. So, 24 in total. About 12. 12 on either side. Good. Okay. Now anyone know what structure

this is here? This is basically it's one of the most the largest artery in your body. Anyone know what this is

here? Yeah, that's the aorta. So basically what happens is the aorta comes out your

left ventricle. It goes up and then curves back down. Okay. So this is this is like a projection of the aorta that

you're seeing. Okay? Cuz remember the X-ray is a 2D image but the human body is 3D. Okay? So that's that. Okay. Which

muscle is this here? Domeshaped muscle that goes like that.

Diaphragm. Excellent. Well done. Which organ sits here on the right hand side?

The second largest organ in your body? The liver. Excellent. Well done. Good work. Which organ is here?

Excellent. This is your stomach. And you can see, by the way, there's a massive gas bubble in your stomach. That's

normal. Um because your digestive system can have air in it. Okay, there's only really two organs where it's normal to

have air. First of all, your lungs. It's normal to have air in your lungs and also in your digestive system. So, in

your stomach, in your esophagus, in your intestines, it's normal to have air. Okay? Right. One more structure and

then we can run. What cube is this here? It goes down and splits into two.

Excellent. That's a trick. Well done. Okay, good work. So, this is an example of what a

normal chest X-ray looks like. Okay, let me mute the chat again. So, this is an example of what a normal chest X-ray

looks like. Okay, because basically there's no massive shadowing. There's if you look at the right lung, it's mostly

clear. Left lung is mostly clear. Um, someone's saying why are the lungs much more visible? So, the chest X-ray is

designed to look at your lungs. Okay. Um, X-rays are not good at looking at your heart. For example, you do a

different kind of test to look at the heart. If you want to look at muscle, it's also a different test. Okay. But

X-rays are very good at looking at bone and very good at looking at lungs. Okay. Those are the two things.

Cool. Okay. So, now we can move on to the next section. So, we've done airways, breathing, and then we move on

to C. C is for circulation. Okay. So let's go back to Bob and have a look at circulation.

So let me know when you can see Elsenor Bob. A is for airway.

Uh anonymous is asking very good question. Uh they're asking on you said the right lung is bigger than the left

lung but why does it look bigger on an X-ray? Very good question. So remember X-ray is a 2D image uh and therefore it

it depends on the projection. So for example, if you have the X-ray slightly tilted, if you take an X-ray of Bob like

this, then the left lung would look bigger than the right lung. But if you take it straight on, then then you're

able to see the difference. Okay, that that's why it depends on the projection. is because it's a 2D image. It doesn't

give you a full 3D picture. Does that make sense? That's why you see the difference. Okay. Now, let's look at

circulation. Okay. Circulation is very important. And by the way, you know, these organs are important like the

lungs and heart because they're very well protected. So, your lung and heart are protected inside the rib cage. It's

um so you have 12 ribs that um are made of bone and they have cartilage at the front. You have the

sternum. You have the vertebrae at the back and each then l the lungs have the plura which cover it which protect it

and then the heart has a paricardium which so that that's how you know these organs are very important because

they're very well protected. Okay. So the heart is one of the main organs of your circulatory system and

the heart is protected by this fibrous layer called the paricardium. Can you guys see this paricardium? If I remove

it, you'll start to see the heart. Um, so let me remove this. This is a layer of the paricardium. Now you see the

heart surface. The heart is basically a very special muscle. Okay? It's it's a very remarkable muscle. It's the only

muscle in your body that never gets tired. It beats from the moment you're in the womb till the moment you die. So

it's it has to continue never get tired for your whole lifetime, which is very remarkable for a muscle. Like imagine

like you go to the gym and you do like bicep curls. Within like a few minutes you'll get tired. You get lactic acid

build up and you get tired. But the heart is unlike any other muscle in your body. It never gets tired. Uh and the

heart is surrounded by the paricardium which which protects it. It also has this yellow stuff. Anyone know what this

yellow stuff is on the heart? Let's have a look on in the chat. Anyone know what this yellow stuff is called?

Yeah, this is uh this is fat. So, paricardial fat. But actually a small layer of fat is is good for you. It's

protective. It's we worry about it when it gets too much. Okay. So, there is um paricardial fat here. It protective but

it could get serious. And then you have the heart has its own blood supply. The these are very important arteries

that that if you um as you get older you can get um clotting there, build up of cholesterol there and it could cause

plague buildup. Anyone know what these arteries are called? The very important arteries that are supply the heart with

blood supply. Well done. So these are called the coronary arteries. And these are the arteries by the way that get

blocked up when you have something called a heart attack. So when you have a heart attack the the arteries the

coronary arteries they get blocked up and then you won't be able to supply blood to the muscle of the heart and the

heart muscle dies away. Okay. Um so this is the coronary arteries and then if we look close at the heart the heart is

basically made up of four different chambers. Okay. So this is example of the right hand side of the

heart. You can see that blood supply comes back to the heart through these massive veins here. Anyone know what the

largest vein in your body is called? The one that's draining right into the heart. You can see it here. Actually,

this vein here, the vennea. Excellent. This is this is called the inferior vennea here. And this one's called the

superior vennea. They come in to the area called the right atrium. The right atrium then pumps blood to the

to uh the right ventricle which then pumps blood to the lungs. Okay. And then inside the um heart you have these

structures here. Anyone know what these structures are called here? This structure here. This structure here.

Very very important. They're called valves. Yes. So they don't they only allow blood to flow in

one direction. So they avoid uh back flow. And by the way, what's very interesting about the heart is that the

right side kind of mimics the left side, but there's subtle differences. Okay, so this is the left side of the heart and

this is the right side. Okay, you can see the left side of the heart is subtly quite different. The left side of the

heart pumps blood to the whole body. So, which side of the heart do you guys think has the thicker muscle?

And you can see it actually here. You can see the left side of the heart. Can you guys see the muscle of the heart

here? The left side is much thicker. Well done. Because that pumps blood to the whole body. Okay? It needs to pump

blood at higher blood pressure. Does that make sense? Um whereas the right hand side only needs to pump blood to

the lungs and therefore that's why the lungs are quite close. So therefore the right hand side is not as as um the

muscle is not as big. Okay, not as strong whereas the left hand side has to have strong muscle. And then you also

see subtle differences. For example, can you guys see they have they both have this valve. This one is called the

triricuspid valve on the right hand side because it has three cusps coming in. Can you guys see the three different

parts, three leaflets whereas on the left hand side you have the bicaspid valve. This is also called

the mitro valve. Okay. Um so this has only two cusps. This has three cusps. Can you guys see three different parts

coming in? This is only two parts coming in. Okay. Uh and then what happens is so blood goes to the lungs. It comes back

oxygenated. It goes to the left atrium. Then left ventricle. Then from the left ventricle through this structure here

called the aorta, blood goes to the whole body. Okay? Oxygen blood goes to the whole body.

Okay? Can you guys see the aorta goes up and then curves back down. And this part is what we saw on an X-ray. We saw the

the knuckle here. Okay? Okay. So the knuckle and then goes down uh descending aorta

and thoracic aorta. Okay. And abdominal aort. Okay. So aorta is basically the major artery.

Okay. Of your circulation. Cool. Any questions at this stage? So let's go back now and see how do we

assess circulation. So circulation, how do we assess? So does a patient look pale and clammy?

Because that means the circulation might not be um pale and clammy. So that means the

circulation might not be working very well. You can listen to the heart. You can listen to the heart sounds if you

have a stethoscope. uh you can also measure the heart rate. So the heart rate should be between 60

and 100. Now remember this is very individual. For some patients say an athlete their resting heart rate could

be 30. So it depends on the person but in general if you take like the population it should be between 60 and

100. Now blood pressure normal is between 120 over 90. Anything over um 140 systolic that could be a problem.

140 systolic. Okay. So systolic is the higher number. Okay. Your blood pressure is two different numbers because one is

done when the heart is beating when it's contracted and one is done when the heart is resting. That's why

there's two different blood pressure measurements. Systolic is the higher number. So So

this is why you have two numbers when you measure blood pressure. The systolic is when your heart is contract when your

left ventricle is contracted. So that's the maximum pressure. And then the lower one is when it's relaxed. That's called

the diastolic. Okay. And yeah, you're right. Each one has different uh thresholds. Okay. But in

general, if the systolic is above 140, then you're worried that the blood pressure might be a bit too high. Okay?

Equally, if it's lower than 100, then it might be too low. Cool. And the other thing you can use to

test uh circulation is to do something called a cap refill. So the way to do this is you squeeze over the nail bed

for two seconds and it should turn white. Um and then you if you release it, it should return to normal color

within two to three seconds. Okay? You can actually do this on yourself. So if you press on your nail bed for two

seconds, hold it for two seconds and then let go and then your finger should come back to you if your finger should

go pale and then come back to normal within 4 seconds. Okay. Don't worry, by the way, if it's delayed a little bit

because if it's cold weather, this it might affect it, but it's a good way to test.

Nail bed is where your nails are. That's that's your nail bed. Cool. So this is called the cap refill

time. Okay. And what can we do to fix any problems or find any problems with circulation. So basically we can

administer um a canula which is when we put uh something into the vein a needle into the vein and then you can give

intravenous fluids goes really low then um you can give them introvenous fluids. Um, by the way, if you suspect a patient

is bleeding and they have a really low blood pressure, what else can you give them to um to try and get their blood

pressure up? Yeah, you might need to give them a blood transfusion. Okay, anyone know

what universal donor blood is? O negative. Well done, you guys. Very good. Very good. So, O negative is

universal donor blood. Okay, good. So you can also take bloods here with can and you can send them off

for different results and you can also do an ECG which is an electrical reading of the heart and you can see what the

the electrical activity of the heart is saying. So this is what it looks like. Okay. And then then once you're happy

with that you can then move on to D. D is for disability. So in disability you want to measure three different things.

You measure the conscious level again. So the apoo score we then measure blood sugar levels as well. And then also you

measure pupil response. So basically you shine light into the pupils and then you can measure the um

the response to that. So when you shine light in someone's eyes, the eyes um should contract because you don't want

to get enough more light into them. Does that make sense? So that's what happens. Okay. So when you shine light someone's

pupils, they should contract. And what's very interesting, by the way, is that if you shine light into one eye, so the

right eye, the left eye also contracts. They should both contract. Okay? Um, and if they stay dilated, if they stay

big, then that could be a sign that they have a problem with their reflexes. Okay? Actually, the reason why we test

this, by the way, is because D is looking at the nervous system. So, in fact, let me show you guys what the

nervous system looks like because that's very important. [sighs and gasps] So, I know we covered

uh the heart and and the lungs. Um but actually all of this is basically to protect the actual most vital part of

your body which is your nervous system. Your entire existence is basically this. This this is this defines you. This is

like your personality, what you do, your actions, your memories, all of this is inside this

nervous system. Okay? Um, and your heart and lungs are there to basically provide oxygen and blood supply to your nervous

system. Okay? And that's why it's so important. So, this is this is what we're testing in D. Uh, by the way, can

you guys see Bob? Wait, I forgot to let's see. Can you guys see Bob, by the way, cuz I'm I'm talking, but I don't

know if you can see him. Okay, perfect. You can see him. Excellent. So this is who Bob is the nervous system okay of

Bob and this is made of many millions of neurons basically that talk to each other but the reason why you shine light

into the pupils is because the pupil the the light will then get picked up by the eyes and then it will send a signal to

this part of your brain. This part of your brain is called the brain stem. Okay. Okay. So, basically what you're

testing when you're doing reflexes, you're testing the brain stem. Um, and your brain stem is basically the area of

your brain that controls your consciousness, that controls your body, that controls your breathing, your

respiratory rates. Um, and if if there's any damage to this area of the brain, basically you you you will die. This is

like a deadly area to have any problems. Okay? And this is why actually when you assess if

someone's has passed away, you test their reflexes, you test their brain stem, okay? You test their heart as

well, but mainly you also test their brain stem, okay? To see if it's there's any sign of life. Okay? So when you

shine light someone's pupils, both of them should contract. So if you shine light into the right eye, the left eye

would also contract. Okay? Both of them will contract. Uh, if someone's brain dead, then

they're technically dead. Like that's how you pronounce someone dead. Does that make sense?

So this is how your brain looks like. Okay, this is your nervous system. This is called the central nervous system

here, your brain and spinal cord. And then all these nerves that come out, this is called the peripheral nervous

system. Okay, we'll cover this in a different session by the way. Uh we're not talking about the the nervous system

as much today, but basically indeed you're testing the nervous system. Uh Rafa saying, "So there's no coming

back from brain dead." Yeah, there's no coming back. If someone's if someone's brain is the reflex is not working, then

that's their brain dead. That's how you announce someone is dead. Cool. Okay. So

this is disability. Okay. So someone's asking about the hypothalamus. Um, let me quickly show you guys because

actually this is what's also fascinating about the human body is that the hypothalamus

in the chat. What do you guys know about the hypothalamus? Let's have a look. What do you What do you guys know about

the hypothalamus? It's the master regulator, right? The master gland. The one that regulates all

the hormones in your body. Okay, is that right? So,

so the the hypothalamus is a remarkable structure and it's it's where all your hormones are regulated.

So, your all your endocrine hormones, your estrogen levels, testosterone levels, LH, FSH, all of that, cortisol,

everything is regulated by this master gland. Now, you'd think something so um that has so much power would be like a

huge structure, but actually if I showed you guys what the hypothalamus looks like. So, this here, this is your

pituitary gland. Okay? And then the hypothalamus is this tiny structure here. This is the

hypothalamus. Okay? This structure here, this tiny structure here is called the hypothalamus. If I

zoom out, it's actually so small compared to the entire brain. Can you see that? So, this tiny structure in

inside near your brain stem is what regulates all your hormones. It's actually kind of remarkable, isn't it?

Um, and this is a pituitary gland. Again, a massive gland in your it controls all the hormones in your

bloodstream basically. And it's basically some tiny dot compared to the rest of your brain. Isn't that

remarkable? So this tiny thing controls your hormones in your body. Kind of crazy. Anyway, let's go back. We get

distracted. By the way, some of this offshoot knowledge you don't it's not going to be tested in the quiz. So don't

worry about making notes about everything cuz it's not going to Don't worry, okay? I'm not the test won't be

that mean. Um so yeah this these are your the things

we test in disability and then we move on. E is for everything else. So E is for headtotoe examination.

Uh if the patient is awake you take a history. If the patient isn't awake they're unconscious. Anyone know how

else we can take a history? Who else can we talk to? Anyone know? Yeah. Friends and family and next of

kin. You could talk to them and gather history. And then you also at this stage you might want to order other

investigations. Okay. Uh so yeah that's what happens. So then remember when you're doing this at any stage don't

forget to ask for help. Okay. You're not doing don't try and do this all by yourself. Always ask for help. You'll

have a team around you and they can help you. So now we've been going on for an hour

now. So let's take a short break and then we can come back and do some cases together. Um,

let's have a look. Any questions at this stage? The chat is still going a bit wild.

I'll keep the chat open for now until we move on. Someone's spamming the alphabet, which is

kind of nice. Wonder if they're okay. Ryan. Ryan, are you okay?

Uh, then who else? What's going on? Um, how long? Oh, the chat is moving too

crazy. It's very difficult to read. How's Bob? Bob's good. Yeah, we'll take a break for uh let's

take a 10-minute break. So, we'll be back at quarter and then we can talk through

some patient cases. Okay. So, be back at quarter, everyone. By the way, please continue to upvote

each other's questions. If you um like the question, then I can answer at the end.

We'll be doing these sessions every Sunday uh for the whole of October. So, um hope you guys will make the most of

it. Right, let's take a break. So we'll be back at 15 past and then we can do some

patient cases. All right, guys. Type in the chat, right, Ron? Type in the chat if you're

back. Let's have a look. Chat's going to go wild now. Back, back, back. Okay, cool. Awesome.

Right now, let's jump into some patient cases. Uh, by the way, how did you guys uh find like am I going into too much

detail? Is it okay? Um um you don't need to know a lot of this stuff. This stuff you might you you'll learn in medical

school, but I just want to want to show you guys some interesting things that maybe it'll spark your interest. Maybe

you go home and read more about it. Uh because the human body is very fascinating. And by the way, that's one

of the things about um becoming a doctor and learning about the human body is that we're still learning a lot about

this stuff. We don't actually know fully how the brain, for example, works. We're still trying to map out all these

different pathways and and find out how how things work. So, there's still a lot to discover. We don't know everything

and we probably will never know everything about how how stuff works, which is fascinating. Okay. Um, and

healthcare will probably change drastically over the next uh decade decades coming up. Um, so it's very

interesting. Cool. So let's now solve some patient cases together. Okay. So the first case

is of a patient who presents as a trauma call. Uh he's involved in a head-on

collision going 40 mph. Airbags were deployed. Patient found unconscious on the scene. So in the chat, type in which

which from this history do you think is worrying? like what are the red flags here that we're looking for?

What do you think of what you're hearing in this case? What's Okay, so you're picking out. Good, good,

good. Okay, very good. The chat is moving. So, what so fast, but you guys have picked out. So, basically,

a the patient is unconscious. Okay, so we know that that's going to be a lower GCS score, a lower score. So that's bad.

The airbags were deployed. So that insinuates that the accident was quite severe that the airbags were put and it

was a head-on collision as well. And already that's being a head-on collision. That's bad.

Okay. So you know these are kind of things you look out for. Okay. This is a serious incident. And when that happens,

by the way, the there'll be someone in the emergency department. they'll get a phone call uh and it's usually on like a

very special phone and that phone is a trauma phone and it will tell the the trauma leader that look this patient is

going to come in to your emergency department within the next 10 minutes. He's got this history of like head-on

collision. It's very serious. So then you make space for them in the resource department and then in resource you have

a team of people waiting. Okay. And what we do is that generally you'll have one team leader and then each person is then

assigned a a different task. So for example, we'll have some p some um person who's assigned to look at the

airways to be the airway specialist to make sure the airways are patent and to control the airways. They'll they may

have an assistant as well. Then there'll be a doctor that's assessing a toe. There'll be uh another health care

professional that'll be assessing circulation. There'll be another health care professional that's trying to gain

access. So trying to put in an intravenous line or trying to put in um to try and get access into the um

patient's bloodstream to try and give them fluids or take some blood. Um, by the way, sometimes it's very difficult

to get access and sometimes what we have to do, it sounds quite gory, but we literally have to drill, use a drill and

drill into someone's bone to gain access into their bloodstream. Because, you know, the people might think bone is

like uh it's just a a collection of like minerals like it's just calcium, but bone is actually a very live tissue.

It's got it's got it's got a bloodstream. It's got cells. um the cells reproduce. It's got bone marrow.

So if you can't get access into someone's bloodstream

through their veins or through their arteries, then you might need to drill into their bone and then put a canula

into their bone. Okay, that's in very severe scenarios. If you can't get access, okay, so that's an that's in C

when we try and get access circulation. Then there's other team members that are doing various things. There'll usually

be a scribe who documents everything, all the decisions being made. And then depending on what injury there are,

you'll get other team members as well. So if it's uh a trauma injury, so bone involved, then you'd get the trauma

orthopedic surgeons. If there's a suspicion of a brain injury, you'll get the neurosurgeons to come. If there's a

suspicion of a cardiac injury or um lung injury, then you get the cardiothoracic surgeons. So different types of surgeon

will come. If there's a major burn, you'll get the plastic surgeons to come. So in different scenarios, we get

different team members to turn to come. And essentially what you're trying to establish is you're trying to stabilize

a patient and then you're trying to figure out what's going on. Okay. So in an emergency scenario, which type

of scan do you guys think we do commonly? Is it an MRI scan or a CT scan? What do you guys think?

Okay, well done. So majority are saying CT scan. So you're right. So CT scan is a 3D X-ray scan that we do and

essentially the patient will go into a giant giant donut and then this shines X-ray energy in 3D and you can generate

an image. So let me show you guys what a CT scan looks like. So this is an example

of a normal CT scan, okay, of the head. Okay, so this is what normal looks like. You can see it's symmetrical.

You can see that there's a midline. So here uh let me annotate for you guys to see.

So what we're seeing here is we're seeing the brain here and we're you can see that if you draw a line like this,

you can see there's a midline. Okay? So there's this side here. This is the right hand side and

this side here. This is the left hand side. Okay. of the brain. Um, and this is how CT scans are done, by the way.

So, what you're doing is you're you're imagining the patient lying flat on the bed and you're looking from the feet

upwards. So, this is always the right hand side. This is always the left hand side. And you're looking for symmetry.

So, you can see that this is the right frontal lobe. This is the left frontal lobe, parietal lobe, occipital lobe. If

I go down, you see the temporal lobe. This is the brain stem here. and you're looking for symmetry. Okay,

this is what normal looks like. Now, you can also do CT scan of someone's lungs. So, this is what

normal looks like. This is someone's lungs. You can see again the same idea. This is the right hand side. This is the

left hand side. The heart is more towards the left hand side. And you can see the lungs here.

All these, by the way, this is what airway looks like. It's got air in it. These are all the vessels. You see these

light up? These are vessels. All the um pulmonary vessels. Okay, that cuz the lungs have a lot of vessels and they

also have a lot of airways. So this is this is the airway here. You can see it's what the lungs look like. This is

trachea. Okay. You can also do CT scan of the abdomen. So this is what the abdomen

looks like. And what's really nice about CT scan is that you can also look from different

angles because it's um a 3D image. So you can reconstruct it like this. So this is what normal looks like. This is

the diaphragm here. You guys see diaphragm? Anyone know which organ this is here?

Very big organ. Let me see in the chat. Liver. Excellent. Well done. Uh, anyone know what organ sits

right next to the liver? Oh, let's move this this organ here. Anyone know what organ this? Can you

guys see this? Like, so this is your gallbladder. Excellent. Well done. It stores bile.

Anyone know which organ? Which organs here? This one

and this one. Your kidneys. Excellent. Well done. Notice how your kidneys are really far

back. They're basically right next to yours your vertebrae. You see that? These are the vertebrae. These are your

kidneys. These are the back muscles. If I go in front, you can see the abdominal muscles

here. I see the abs here. This is muscle. Muscle, intestines.

Okay. So, this is what we do. We do a CT scan. Okay. So, now let's have a look at a CT scan of our patient. Okay. Uh, so

let me mute the chat again. So, let's have a look at CT scan of our patient that went through a trauma call. Okay.

Okay. So, first of all, we'll have a look at the head. So, this is what we saw when we do a

head scan. So, what do you guys think? Normal or abnormal? Type in the chat what do you

guys think of this guy? And if you're saying abnormal, then which side is abnormal?

Well done. So yeah, this is abnormal. The right hand side is abnormal. Uh and you notice the area of abnormality

is this here. Can you guys see this shiny area here? This is abnormal. And you can see it's abnormal. It's also

causing the midline to shift. Can you guys see the midline is shifted to the left hand side. Now this is the thing

about the brain is that it's inside this cavity called the cranium. Um and therefore if you have raised pressure in

inter incraanial pressure then it compresses on other parts of the brain and that's why we worry in this case. So

what's happening is this area of bright white stuff is pushing the brain to that side. What do you guys think this bright

white stuff is? So this is an X-ray. What do you guys think this bright stuff is? Considering

the patient's just been involved in a car accident, a very severe car accident. What do you guys think it is?

It's fluid, but what fluid is it? It's blood. Yeah. Well done. It's most likely to be blood. Um, so it's

bleeding. There's a brain bleed here. And then if you look closer on a CT scan, you'll see why there's bleeding.

Can you guys see? Anyone tell me what can you see on this scan that that shows why there's bleeding? What's happened

here? There's a crack. Yeah, there's a fracture of the skull. So, this patient

has fractured their skull and underneath that you can see an area of bleeding. And also, what do you notice if you guys

were to see the patient in real time? What would you notice on them? Can you guys see there's something here? What

would you see visibly? A swelling. Yeah, you can see the head is swelling quite badly. Is that right?

You can see that here. Okay. So, we've established one injury. So, this person's got a brain bleed. This is very

serious. We need to act on that. Now, let's have a look at other injuries. So, now we've done a

CT scan of the chest as well. So, full body CT scan. Now, what do we notice here?

Let's go through it. So here this looks totally abnormal. And

which side do you guys think is abnormal? The right hand side or the left hand side.

Yeah, good. The right hand side. Now notice, by the way, there's an injury pattern. So the injury in the brain was

on the right hand side and the injury in the lungs is also on the right hand side. It makes sense. it it's in keeping

with the history that we've got. So basically what we can see here is again there's an area of bright fluid. This is

likely to be blood. And then we can see why this happened. By the way, can you guys see

what what's happened here? that what's happened here that's causing the bleeding underneath it.

Yeah, they cracked their ribs. Good. Well done. You guys are very good at solving this. So, this patient has

basically broken several ribs. There's area of bleeding and then we've put in a tube to try and drain the bleeding. And

then if I keep going down, we [clears throat] can also look at the abdomen as well. So, let's have a look

at the abdomen. Um this is the top of their abdomen. You

can see what else has happened. Which other organ is damaged here?

This is actually a very tough question. Let's see if you guys pick it up. So the liver is actually fine. So this is the

liver. Let me show you guys the liver. There's another organ here that's damaged though. It's not

Oh, this is a line. No, no. So this is the liver. The liver outline is actually fine. But there's another

organ here that doesn't look right. Okay. There's another organ here that there's an injury. Anyone know what

organ is injured here? This is a very tough question. Excellent. Let me mute the chat. So the

kidney actually. So if you look the right kidney here is what is shattered. This is very bad

news for the patient because can you guys see this kidney here? Doesn't look like the kidneys that we know how they

look. This is how a normal kidney looks like. This is what this kidney looks like. You can see there's there various

outlines, various So what's happened here? This kidney is actually broken and all the stuff inside the kidney. So

urine is seeped out and blood has seeped out into the abdominal cavity. And the reason why, by the way, is if you look

closely, can you guys see what's happened here? Let's let me unmute the chat. Anyone see

what's happened here? What how did this kidney get injured? Yes. The ribs that were cracked, they

also cracked. So they not only cracked the lungs, but they also cracked the kidney. So in this case, what needs to

happen is this kidney is going to be bleeding um and leaking all the urine. So in most cases this kidney will get

removed completely. Okay? You'll get something called a nefrectomy. This whole thing will get removed. Actually

the surgery to do this is very fascinating because sometimes they use robots to do it.

So they they use robots to operate on this to get rid of the kidney. Okay. So that's um very fascinating.

But anyway, so this patient has several injuries. Now another injury that the patient also has unluckily is that

they've also fractured their hip as well. They've got a hip fracture as well. Okay. So a lot of injuries in this

one patient. Okay. So what do we do next? Now the patient will need to undergo

um an operation to stop the brain bleed going anywhere. Stop the bleeding on the

brain. Do you guys want to see this? This is quite gruesome, I must warn you. So, let me know in the chat if you want

to see it. Okay, so the chat United says, "Let's watch it." Okay, come on. So, let's have

a look at this. So, this is an example of a neuro operation. Okay, let's Okay, let's go back to the start.

So, They take they take a uh >> so what happened is a surgeon was being

called in. So that's what happens. Surgeon is usually at home and then they're being called in. Emergency, you

have to act right away. Right now what you what we're doing is we've um put the patient to sleep. We've shaved the skull

and then we've marked the area of where we're going to make a cut in the skull. Garrison.

>> Yeah, I don't think we're going to need that. We do. We're in trouble. Know what I mean?

>> But we're calling into the skin right now. The skull. The the skull. I mean, >> Yep.

Not back in a minute. >> Mhm. This woman is very malnourished

obviously. You got your perforator ready? Good. Beautiful.

Uhhuh. While we're doing this, let me have the >> Now what we've done is the surgeon has

taken a skin flap, reflected it over. Now you can see bone under real quick. >> We'll move in the mont.

Now we use a very special drill called a stereotactic drill which basically only drills bone. It as soon as it hits any

soft tissue it stops automatically because otherwise you're drain you're drilling straight into the brain. You

don't want to do that. So we're creating what we call bare holes. So this drill can I see this drill? The

surgeon is drilling right into the skull. the epidural right there. Let me see a

curette, please. Thank you. Let's get rid of some of this.

space. Yep. >> That the bone is an active tissue. That's why it's bleeding. You see the

bone is bleeding fast. And then we're going to try and create >> several but holes.

But if I don't say more but holes now get a cushioning so temporal in your hand if you can retract it.

Now we're making another but hole and we'll we'll do a fill between the bar holes

flaps. There's one so cut there. Now we're cutting between the B holes

and then we now remove this. Hold on. Let me have a bone please. We now need to locate the bleeding and

stop it. Actually, you know what? It's not bone that's bleeding.

Well, there's mystery here. It's a big epidural. Big one. Okay.

Clean this up. We have an elevator, please. Peroxal elevator. Let's get rid of this.

It's a big epidural here. That

n Let's have some irrigation. Please just keep irrigating in there.

The sudden has located the bleeding and stopped it. Can you guys see this massive clot here that 30 off?

Let's have some irrigation there. Just keep irrigating in there.

So that's where the bleeding was. Now the bleeding is >> you can put everything back together.

three frames everything back together >> and then we can put back on like that >> the skull flap

>> with some screws that put it in place probably >> and you basically saved the station's

life >> operation's done crazy right this is a neuro operation

brain surgery. Let's have a look. Any comments? What do you guys think? Quite

remarkable, isn't it? This operation has to be done very quickly. So, you can see the

surgeon was actually acting very quick to find the area of bleeding. So, it's done within like an half an hour to an

hour. This operation is done. and you save someone's life and there's a lot of blood. Yeah, of course

this is very risky. And if this operation didn't occur, by the way, the patient would have probably died because

the bleeding would keep going. It'll compress on vital structures in the brain and might even compress on the

brain stem and then cause brain stem death. Cool. Let's do a quiz now.

Which of the following is a primary assessment priority in managing former patients?

So if it's not done fast enough, then the the patient will will pass away. This is life-saving operation.

That's why I have so much respect for neurosurgeons because it takes many years and dedication to become a

neurosurgeon. It's not very easy and actually you have to have very good visual awareness of um and you have to

be very competent with your hands as well. It's not an easy skill set at all and you have to act under pressure,

immense pressure. So, it's one of the most I guess one of the most rewarding types of surgery but also one of the

craziest. One of my best friends from medical school, he's a neurosurgeon and he works long hours all the time. I

think the longest operation he's ever done was 18 hours long. Can you imagine doing an operation for 18 hours? Um, so

it was very crazy. But I I trust him with my life. He's one of my only friends I fully trust

completely because he's so remarkable. He's very confident, very very competent, very knowledgeable.

Right. Next question. Which of the following is not an essential component of the initial trauma screen or

assessment? Someone's in injecting some code into the chat. Is that is this going to work?

Like what's um or someone spamming the alphabet some weird characters.

Excellent. Okay. So you're right. So fracture moation is not part of the initial trauma assessment. Remember

airway, breathing, circulation is so well done. You guys are very good. Well done.

Right. Which is the purpose of the GCS score. By the way, can I say you guys are very

good. Well done. You guys seem seem to know a lot. Um at your stage, I certainly had no idea about any of this

stuff. So very well done. So yes, so glazicone has to assess neurological status to assess

consciousness level. So very good. Next question. In an emergency trauma setting, what is

the single most useful imaging modality? By the way, I just realized we have 108 arms raised. So,

we're going to go into the Q&A section after this. Um, so if you have a question, I could unmute you if you'd

like and then you can ask your question out live. But um if you've got your hand raised and you don't intend to ask a

question then can I ask you to unraise your hand so that I know who actually wants to ask a question and who uh is

not wanting to ask a question. So we have 140 arms raised. Okay. Which of the following is a potential

complication of trauma in the emergency department? a complication. So, what usually happens

following trauma and you're right, it's well, people are typing a in the chat.

A well done. So, hemorrhage. So, bleeding is is a major complication of of a major form. Okay. And last

question. Is this CT head normal or abnormal? What do you guys think?

Remember, you want to look for symmetry. The quizzes on menty by the way. So, if you can't get in then it's because you

can't get access menty. Don't worry, the end of uh sessions quiz will be uh something you can access. So don't worry

if you can't access the menty quiz right now. So yeah, this is abnormal. Well done. Very well done. Excellent. Let's

have a look who's in the leadership board. Who's won? So Sakuru

Sakura, well done. Excellent. Right. So now we have 15 minutes left.

So we can go to Q&As's. Before that, let me show you guys some more examples of of trauma or uh of stuff that happens at

accident emergency department. So let's have a look at this one.

Anyone know what happened here? Yeah, broken finger. Good. It's a dislocation. Anyone know why this

happened? Yeah. So, this patient was trying to catch a basketball and then they caught

it wrong and then this is what happened. Let's have a look at more trauma scenarios. This patient

uh is one of the luckiest patients alive. So the history of this patient is that um he was climbing a tree. I think

his job is a tree surgeon. He's cutting a tree and then he accidentally slipped and fell over and then this is what

happened. A branch went into his neck. Okay. By the way, these cases I'm showing you are all anomalized.

anomalies and also the patients have consented to the to their cases being shared. Okay. So remember one of the

main principles of um dealing with patients is confidentiality, right? So everything show these patient these

cases are teaching cases. Okay. So you can't identify exactly who this is but they've agreed for their cases to be

shared for teaching purposes. Okay. So this patient basically fell over from a tree and then got impaled by a brick by

um a um a twig uh actually quite a large branch. And by the way, this patient is really lucky because

so it went into their neck and if you look very carefully you can see the branch here. This is the branch, the big

branch going into their neck and it just misses their trachea. So it doesn't go into the trachea and then it's literally

Can you guys see this here? This structure here this is the biggest artery in your body. Anyone know what

artery this is here? The aorta. Well done. And this is the branch. Can you guys see how close the

branches to the aorta? It it's literally a millimeter away. And what would happen if this branch went

straight into the aorta? What would happen do you guys think? Remember the blood pressure in the aorta

is very high. Yeah, you'd die very quickly almost instantly because you'll get a major hemorrhage and the aorta has

got controls all the blood supply to your whole body that be devastating. But so

the patient was so lucky that the branch went so close but didn't get to the aorta. And if you look at a 3D

reconstruction, you can see how close it was. So this is reconstructing

how close it was to the aorta here. Can you guys see the branch? It it almost touches the aorta, but it doesn't. It's

1 millm away. And this patient survived. So then what happened is it had an operation to

remove the branch and they survived. Crazy case, right? Look at this. how close it was.

And what also is remarkable is that in your neck you have so many different vessels and and so for example you have

the corroted artery here you have the jugular vein um you have all the vertebrae the your cervical spine the

branch had missed all of that. It's actually very tough to actually miss all those branches because your neck is full

of vessels. It's full of um it's a very special place of your body. So a very lucky patient. This patient

survived. Let's have a look at other trauma cases. Uh this one

what happened here? So anyone know what happened here? Actually a very sad story this one.

I can show you a different angle or the different type. But this is so this is not a car accident. This is

actually this happened in the states. It was um a shooting. So you can see the bullet it entered

and exit. You can see it goes straight. Can you guys see there's like a line? There's a line here. That's a bullet

traveling through and there's all bleeding here. This is bad news. This patient did not survive that. This one's

another example of a bullet going through the lungs. Can you guys see the tract? The bullet going through. This

patient survived because it missed their heart. Very close to the heart, but it missed their heart. It just went through

the lungs. Can you see the bullet tract here? Okay, let's have a look other cases.

This actually looks really bad, but this patient um survived. Anyone know what we're looking at here?

There's actually a baby, a newborn. Yeah. So, it wasn't So, what happened is

this baby was delivered via um a certain instrument. Sometimes if the labor gets complicated, then you have to get the

baby out and we sometimes use instruments to deliver the baby. So, this is uh forceps. Now the problem with

baby skull is that it's very um very malleable. So this baby during forcep delivery there there was uh

this is how the baby was born but then the baby survived. So child birth is very traumatic by the

way. Child birth can can get traumatic. Um luckily nowadays we have very good health care that most child care most

child birth um happens uneventfully but in the past people used to die during child birth you know it's and it's still

common that that um injuries happen um but luckily with modern healthcare this is we can change that. So this poor baby

baby was delivered you're using forceps but the reason being is because if the baby wasn't delivered then they'd have

if you don't deliver the baby within certain amount of time frame then the baby will struggle the mother will

struggle and they both end up having catastrophic problems. So this is best case scenario.

This patient was delivered successfully. There's some injury to the baby but they were able to get better. Let's have a

look at some other injuries. Uh let's have a look at this one. Anyone know what's injured here?

What organ is injured here? Anyone be able to interpret this? So here this one is the left eye. Can

you guys see the right eye looks normal? The left eye is injured here. Can you guys see that?

This is what normal eye looks like. This is what abnormal eye looks like. You can see it this angle as well.

Cool. All right, guys. So, we have 10 minutes left. So, let's go through some um questions and answers. Let's have a

look. Let me see the Q&A. Uh okay, the Q&A's got 1,600 questions. Uh

so, let's have a look. Maybe I can try and rank them and see which ones have the