here we go it's presenting the case how to succinctly present the case and demonstrate
that you get it so you get what's going on and the aim here is to really try to simplify some complex
situations um or potentially complex situations uh think like a boss and predict the critical issues
i i go on about this point often for my senior trainees but i want to just give you an example of
that now as well um when i talk about the critical issues is the fact that in any area of medicine
in any area of life really you will go through the bread and butter stuff of what you do the day in
day out stuff time and time again so you will eventually know what normality is for example
in the anaesthetic history i mentioned a very very brief history that you take
all of that's very normal you'll get so bored of that but one day you'll have a patient with some
crazy av malformation awesome or hemophilia or they're a jehovah's witness having a multi-level
you know lumbar laminectomy or something like that suddenly that normal case the only thing
that really matters because everything else is very normal is that critical issue and so i
think it's really useful to be able to summarize everything in a very in a practical way and also
mention these critical issues so what are the magic words i think it's very safe to
say age gender and the surgery the risk level of what you perceive it is high moderate or
low is it elective or emergency because that dictates how you know how much time you have
to optimize or whether you have to crack on or not and what these critical issues or main issues are
in our world of training often we're in tertiary hospitals so we're in the place that we need to be
in but say you're you know in a peripheral hospital you're in the country you're in a
in just in a smaller center suddenly that location actually matters and when you
as you get more senior training and become a consultant you'll make some very hard decisions
about what's appropriate in that space in this in in the theater that you're working in or not
i also start thinking who do i need and i just want you to think about these very
consultant level think things that you think about even now let's crack on with this so
after i say that i can then say this phrase in more detail so this is where you get down to the
specifics if your consultant wants to learn more so your consultant will really appreciate when
he or she can glance at a chart just imagine you filled it with neat writing all the relevant info
that's written down neatly and in order so again see page six to eight um but essentially
if you were to write down for a very normal examination history just these things that
you can see in front of you no general anesthetic ponv family history issues heart lungs are good
medications no allergies fasted with no reflux and you've documented a decent airway exam once once
i glance at that you don't really have to present that to me you can just i can just see that you've
gone through everything so i'm trying to try to i'm trying with this talk to get you to mention
the things where you're synthesizing what's in front of you and adding value to what you've
already written down because i could read what you've already written down very easily you don't
have to say that to me it'll be it'll be boring for you and boring for me and add no value to
the situation so again this is take this and use it with judgment um maybe some consultants want
to know everything maybe they want you to speak it out loud but i get the feeling that you can
mention certain things with this technique and get down to a lot of very useful stuff and this is one
of the techniques i'd tell my viver the students the trainees going through their final exam
as well so to emphasize this once we've gone through all of these normal things
we then go through you know i can easily see that you can mention what what really matters to me
example you assess a patient you panic a little bit you then eloquently say to briefly summarize
there's an elderly male for a high-risk emergency procedure the main issues are critical cardiac
disease and a bmi 45 and the patient requires tertiary level care and input from cardiology
post-op so i'm hitting those points of you know gender age risk level is it elective or emergency
and what are the main issues that i think above and above the normal assessment that i've done
and what do where do they need to be and maybe who do i need what services do i need afterwards
so let's give this a crack this first one's a relatively straightforward case but just see how
you can add value and just present it literally in the way that i've just described a 45 year
old male presents inguinal hernia repair past history of smoking hypertension and cholesterol
very active 45 year old male inguinal handy repair pretty straightforward it's a relatively
low risk elective procedure and i've just said a few cardiac risk factors but i'm not really
not concerned great exercise tolerance and maybe i've discussed smoking cessation
in more detail and then i show the case scenarios uh let's get to a few more interesting ones now
fifth year old female presents for lap collie pastor history hypertension runs marathons
and then these are the scores we'll go through the airway assessment stuff for those that don't
know it melon patty 4 is a bad score environmental distance of 5 is not great and small mouth opening
is obviously not great as well so just say what you do to present that to me i'm using that same
format to briefly summarize 50 or female for a lap collie relatively low selective procedure
dominant patient issues exactly what you said potentially difficult airway and
we can get into details uh about how you would approach that in the airway section
but what as you can see what i've done here will go through this in a lot more detail differently
intubation due to what i found but i do then make the assessment that bag mask and lma ventilation
should be fine based on my findings and i'll show you how we how we come up with that later on
and my plan is like you said use a video scope um and just know that some of this
may not be what you need to say you know the after a while you'll you can you know you'll probably
realize that it's just so obvious that this is a lower selected procedure maybe you'll maybe you'll
be able to just offer to your as you present to your consultant like there's a pretty standard lap
collie in this in this otherwise well patient the only issue is she has a difficult airway
and then show them your chart so i just want you to use your judgment um to make it as most
relevant and you know show your experience at identifying the critical issue if everything
else is pretty normal and then showing your well-written chart to your anesthetist
uh keep going six-year-old male presents for total knee replacement hypertension diabetic
active reflux on even on an empty stomach and knee pain on a hundred milligrams of oxycontin daily
and that's pretty good again it's not not too difficult to identify that he's got a
you know the main issue here is the post-op pain that might be difficult to manage and then you
can go through in more detail what you do and my plan could be an rsi and usual analgesia regional
spinal and or ketamine if i spinal ketamine if i decided that and again my aim here is to
as you can see a lot of these patterns of cases will slowly come up over and over again
and there's no reason why you shouldn't already know these patterns uh you know as you're starting
your anastasia rotation rather than over two years so again just drilling a lot of these
common concepts will make hopefully a rotation at least the knowledge element much easier so
that's right six-year-old male total knee replacement moderate risk elective procedure
dominant patient issue is an aspiration risk and may have post-op pain that's difficult to manage
and in more detail i can go through whatever plan that i decide on a 90 year old female from a
nursing home with a fractured knock neck a femur fracture for open reduction internal fixation
uh frail dementia death hypertension cholesterol osteoporosis glaucoma incontinence and an unknown
exercise tonight it's a very typical fractured enough patient yeah a lot of good things there
um so i've said to briefly summarize ninety or female fraction of rf um i call it high risk
because the mortality postop really is quite huge and it's a palliative procedure so you're right
in saying it's urgent you know there's a very there's varying spectrums of urgency emergency
would be a ruptured aaa urgent would be something that you need to do in the next kind of 48 hours
which is definitely the fractured knocks the mortality always increases after 48 hours
and you don't really want to delay um and it's often palliative you know the pain relief rather
than any uh and a small mortality and a mortality benefit but you're not expecting you're not trying
to do this to cure anything the pathology of this patient is in everything else as well
and again i agree what you said it's a dominant patient issue high appropriate motivating
mortality maybe the nfr status and i always have a consent and family discussion about the palliative
nature of the procedure and then in more detail you can you can go through all of that as well
good at 18 year old female for tonsillectomy for a current tonsillitis
no previous general general anesthesia very active but suffers asthma occasionally and snores heavily
and reportedly has apneas recently had a cold also mentions multiple family members died
or nearly sorry nearly died under anesthesia and doesn't know why obviously bit bit peculiar
but let's go through it so i think this is an 18 year old female who's presenting for an elective
tonsillectomy and what is likely to be a moderate risk procedure given a history of asthma and
this unclear family history um which i'd like to explore more i suspect her main issues will be um
well this family history um and whether there's any underlying allergies and also potentially a
level of anxiety that might come with fantastic and when you hear snores heavily and apneas
what are you thinking of then uh thinking also maybe some undiagnosed osa fantastic and this
is a peculiar situation because uh there's always there's often a hospital will have a wrist matrix
of osa severity mild moderate severe on one axis and then the risk of the procedure high you know
mild moderate severe risk and tonsillectomy or airway surgery while it's generally a moderate to
low risk operation in osa it's high risk for osa complications there's airway surgery i would say
something very similar h and your female tons of activity with potentially high risk issue
there are multiple issues multiple deaths on the anesthesia like the osa and like in recent urtium
with respiration so i'd have to make different decisions for each of those and in more detail
i could you know go and make my plan um and as you can see again i'm trying to emphasize that if you
by highlighting these important issues you cut you get to the crux of the matter
um because your consultants are often used to hearing all the other stuff so it
just shows a lot of clinical acumen when you when you start saying that now claire you mentioned
multiple deaths under anesthesia being an issue and you mentioned allergies so yeah if i hear
multiple deaths under anesthesia actually i want everyone to have a think about multiple deaths
in the family on the anesthesia what conditions are you thinking what are you worried about so
i'm worried about milking hypothermia sucks apnea absolutely definitely anaphylaxis
if other members have died but doesn't necessarily run in the family um but then the other one that
is often not talked about is just congenital cardiac issues and arrhythmias that are you know
that are hereditary uh so yeah that's that's the things i'd really want to think about
often with the right questioning you can take away these risks very quickly next one 30 year
old female g1p09 weeks presents the labor ward with blood pressure of 160 or 90 headache and
some abdominal pain take about a minute or two and talk through your summary statement
there's a really good question about is this surgical anesthetic risk
i'm just stating this as over my perception of the overall risk because i think that matters
to the way i approach the scenario i don't get into the specific surgical anaesthetic
risk because in this particular circumstance it probably doesn't matter too much i'm just giving
my consultant and my team an idea of how concerned i am in in that in the setting so i would say uh
this is a 30 year old team i was presenting g1 p0 at 29 weeks uh with potential pre-eclampsia
with vp of 160 headache and abdominal pain so i think it's been worked up from that perspective
i'm also to know it's a 29 week premier baby so getting peeds involved as appropriate
uh early on and just giving them that that heads up for the patients coming fantasy that's really
great so you you not only ident so i've given you some symptoms and you've identified that
it's pretty you know it's pre-eclampsia so it's a really fair call to make in this syndrome and you
die it satisfies that criteria you then say you've seen that it's a prem so you know you want to get
other people involved who do i need um where do you want to be ideally where which i think
ideally ideally in a tertiary center where you might have nicu on standby as well for a premier
bay for 29 weeks perfect so i see this case i summarized my boss 30 year old primate preterm
high risk urgent obstetric issue dominant patient issue is likely severe preeclampsia it fits that
criteria and who do i need obs and niku and where do i need to be tertiary obstetric center
and just remember that you can keep adding layers as you gain more experience as soon as i then see
severe preeclampsia i then think of my priorities of management which the obstetrics should have
started but i'll always check for myself um luke while you're there and this is a definitely
advanced question to ask um what what are your priorities when managing severe preeclampsia
i understand that you may have not managed it before
i guess blood pressure interoperability but you're giving uh hypnotist organized to rob your blood
pressure um and help syndrome so coagulation coagulopathies associated with low platelets
and eclampsia means um and what happens at the end of oh and see low entries at seizure thresholds
absolutely pretty quick you actually mentioned the right stuff so the the primary goal here
before operation is blood pressure control all the more most of the mortality events are due to
high blood pressure intracranial hemorrhage so i think blood pressure control seizure prophylaxis
um management of other other organ abnormalities such as coagulopathy that you mentioned and then
finally timely delivery of the fetus essentially you want to control all of those things
and there's no rush to delivery those have to be controlled prior to delivery so again i'm just
adding as i gain my knowledge i layer it on to what my priorities are as i as i learn learn more
facts and then all of those priorities then become their own management steps again you'll learn all
of this in in good time but i really want to give you that structure to hang this stuff onto
final one robert is a 74 year old male ruptured aaa for laparotomy rushed into
the emergency department and you're there at the emergency department reviewing this patient
peripheral vascular disease past history had some cardiac stents hypertension and the blood pressure
is 85 on 40. um what are your priorities oh sorry not what your priorities what is your
summary statement what i've said specifically is again 74 year old male rupture triple a
laparotomy this is high risk in his emergency it's a very high mortality event to have this problem
now so what are again what i've done here dominant patient issues
just over with it with experience you realize that these cases in ed one of the biggest things you'll
have to do is just transfer urgently to theater the only solution to this problem is a cross clamp
and that doesn't happen in ed so often it's about getting the patient up to theatre
with a surgeon and the right team straight away uh cardiovascular instability is a big deal
and that will then lead to a whole bunch of things that you mentioned and you will
would have mentioned as well which is you know big lines monitoring noradrenaline adrenaline whatever
i need and then you also mentioned the fact that very correctly that i need other people hematology
blood bank maybe so as soon as i have a blood loss case like this one there's a whole team that's
involved in resuscitation master transfusion and you'll hear me talking about bundles of knowledge
which you'll slowly be able to gain over your time so as soon as i see a blood loss in a case
i think of this bundle of care essentially which means you know lots of hands another anesthetist
lots of nurses level one for transfusion blood bank massive transfusion and hematologist
um and then maybe even cell saver and perfusionist as well and then finally more surgeons fast
surgeons and maybe icu post-op so that's just like a thing that i can always say because every time
i have a blood loss case i need one or more of all of those things in a bundle together
and like you said this should i this should be done where it needs to be done because it's an
emergency but i i use the phrase ideally done in a tertiary hospital just to make me think that i
do need all of those resources and i need a whole bunch of people as i mentioned before
so again just to summarize age gender risk level that's my perception of the risk level
overall elective or emergency or urgent surgery dominant patient issues critical issues main
issue whatever you call it location if it's relevant who do you need if it's relevant
and then in more detail you can add levels to what the issues that you talked about so just to recap
what we've done now is we've gone through pretty much all of the stuff i'd think about before
theater so just just imagine what that means i've chronologically gone through assessing the patient
a simple optimization steps risk benefit profile considering the highest risk patient for high
risk surgery how to do a very reasonable consent process what are my surgical issues
i can make a basic anaesthetic plan hitting those high points of ga regional ett or lma
paralysis or not which parts of the triad i need what's my monitoring do i need to upscale that
what's my pain plan do i need to upscale that and where does this patient go afterwards
and then i can present the case identifying some critical issues just to sound a bit more nuanced
sound a bit more expertise about what i'm doing um and overall i can you know do a checklist history
uh in neat writing on anastasia chart to show my consultant that i'm thorough as well so hopefully
that all makes sense to you that this is just chronology chronologically done now before we go
into the in theater tasks what i'm going to do is go through what something that really blew my mind
so this next section is the patient with cardiac disease for non-cardiac surgery
you