#119 REPOST: Lung surgery

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All you need to do to sign up is go to pacesahead.com And I advertise for these two sponsors because I genuinely believe that combined they essentially guarantee you'll get that all important parts in Paces. So use the discount code Pre Paces 15 at Quesimed.com and sign up today! Hello listeners, it's your host Dr Sam Williams here and we are back with a second repost of one of my favourite episodes of the podcast. On this occasion I interviewed Dr. Aranthakrishnan Raghuram, consultant respiratory physician at Gloss the Hospitals NHS Foundation Trust. Raghur was such a fantastic guest and lung surgery is a topic which we know comes up time after time in Paces. And I just loved his simplistic pragmatic approach to this station and as an official big dog within the Royal College of Physicians, his advice was invaluable in helping people prepare for this critical station. Listeners, I'm recording this the day before the wedding so thank you so much for all of your ongoing support. By the time you've listened to this I'll be enjoying a wonderful mini-moon in Cornwall with my new wife. And I just wanted to say a huge thank you for all of your support and we will catch up with you in a couple of weeks time where our regular programming schedule will continue. We'll see you then. Welcome to the Pre Paces podcast with me, Dr Sam Williams and today we have a huge name in the world of the Royal College of Physicians joining us on the show. We're delighted to welcome Dr Aranthakrishnan Raghuram known affectionately as Raghuram to his friends and colleagues. Raghuram is a consultant in general and respiratory medicine at Gloss the Hospitals NHS Trust. And not only that since 2015 he's been the head of the postgraduate school of medicine at HE in 7 and is a chair and host for the MRCP Paces examination. He has been a regional advisor, sensor and Lyneca fellow and is now an elected council member at the Royal College of Physicians of London. He was also awarded an MBE in the Queen's Birthday Honours list in 2021. So I think it's fair to say we couldn't have anyone more well placed to discuss any sort of respiratory Paces examination. So Raghuram, welcome to the show. Thank you and delighted to be here. And Raghuram, we're going to be talking about a relatively common station in Paces today. We're going to be talking about lung surgery or thoracic surgery which is obviously going to be in a respiratory examination station which is a station one. And so if we start off, why is it that lung surgery is a relatively common station which appears in Paces? The first thing is if you've got to play the odds with Paces, you don't have to get somebody who's very ill and a lot of patients are being followed up in respiratory clinics who have had some form of surgery. So when you're preparing for Paces, although there's been a myth out there that the greater the esoteric comes an exam, these are common things that come up. It's important to know what would have led to that said surgery. It's important to know what you would do next. So that's why you find a lot of patients who got scars and your job is to try and work out the before, the de-arring and the after without the benefit of the notes or worse, and let it from the surgeons saying what they've done to the patient. So yes, is that unfair? Probably, but that's how it is. Brilliant. And we just had a brief chat before we hit the record button. And one of the things that we just briefly mentioned there is that just having the surgery isn't a diagnosis on its own, which I think is an important thing just to bear in mind is that not only would you be expected to make it an educated guess at what surgery they might have had, but you're also going to be thinking about the underlying diagnosis, aren't you? Yeah, absolutely. It's important to know what has led to that and they'll be clues within the patient's hands, the body, the chest that will give you a likely diagnosis. It doesn't have to be accurate. You're going to give a differential. But once you've got that far, the next step would be to work out because you have six minutes to examine the patient. You've got four minutes. And remember that the examiners have to mark every scale. So make sure that you have an answer in your head. And the trick really is when you get to that one minute warning, most of you would have finished doing the examination by that point. Use that 45, 50 seconds that you've got to try and work out what question am I going to get? And then how am I going to answer that because trying to think of the spot when you're nervous isn't always the best thing? Yeah, absolutely. And I guess the other thing just to say in this in this particular station is that often there's quite a significant overlap for the signs which you may be able to detect. And I guess the main thing as Raghu said is you have to be nailing a diagnosis by the time you're finishing the examination. There's no point making it to your presentation with no idea about what you're possible underlying diagnosis could be if you've seen a scar which suggests the patient has had thoracic surgery. But we will come onto that as we go through the examination in the shoes of our PASIS candidates. So without further ado, let's get into talking about the rassic slash lung surgery. So Raghu, the first thing which we always do is we talk about the end of the bed, which obviously is bread and butter for PASIS candidates. And so what can we typically see from the end of the bed, either looking at the patient themselves or looking around the bed for clues to a specific diagnosis? You always have to start at the end of the bed. And the reason for that is you're going to miss a lot if you straight go into examination. So take your time, look around, check for oxygen, check for anything else that's there. It's a huge important time for me to be kept for you. When you're looking at the patient, they head in the bed. Make sure you position them right. And while you're helping them with the positioning, make sure they're adequately exposed. Go back and watch to see the inspection. The inspection is going to give you a heck of a lot. You might see the scar. We'll come back to what we're going to do if you can't see a scar and ask them to take a big breath in and out. Too often candidates ask patients to take a big breath when they've just taken a big breath in. And this can't breathe anymore. So one of the things I would suggest you do is just gentle breathing in and out. And as they breathe in, I would say let them out completely and then beg breath in and out again. So what you're watching is for the movement of the chest and also you can detect if there is a difference between the movement on either side. Point number one. Two, you can look at the neck. You might find the trachea has gone one side to the other. Again you can pick it up at the end of the bed, which you might forget when you get a bit closer. The third thing which I would suggest you look at is something called trail sign. Now what trail sign is is the sternoclydom mastoid if the trachea is in the center should be equally prominent. Now remember the sternoclydom mastoid is kept in place by the investing layer of the deep fascia. So if the trachea is shifted, that deep fascia becomes lax, which means that sternoclydom mastoid is prominent. And that is a very good clue when you're sitting in the edge of the bed that you might miss when you get too close to the patient's moving. So that's one thing you can do at inspection. The other thing you can do is to see whether the patient is breathless, you can counter-sperit rate, and you can check if they're coughing or not. So you've got a huge amount of information long before you've got anywhere near the patient and you're mentally clocking in your head all these things. So that's about the end of the bed. We then move on to actually turning around to see the patient. So when you're coming around to see the patient, have a quick glance around you and then make sure the patient is comfortable, make sure your hands are warm because often you'll have your nervous and it's cold out there and your hands be cold. There's nothing worse than having cold hands. So warm yourself up. So when you get to examining the patient's hands, think about what you want. If you're clubbing, if it's there, it's great. Make sure you demonstrate that finger clubbing and you have a differential diagnosis for that lung cancer, spronchi excess infection scarring. And that's quite useful to do. And I find a lot of candidates looking for a flap, looking for a bounding pulse, looking for carbon dioxide. So you're never going to find that in real life. If you do somebody's gone something really wrong, make sure you do it to demonstrate that you are doing it. But if you've seen it, then there's something wrong there because they put a very sick patient in the exam. Remember, the exam does not want the patient collapsing on them. You're also looking to see whether there's any tobacco staining because that you can introduce into your managing patients' concerns. So when you're getting there, you can say, "I've noticed the tobacco staining. I will ask about smoking cessation." There's a little tips that you can get while you're getting there. So that's about the hand and then move on to the face and look to see whether the patient's anemic or the patient's sinus. Now apical tumors might give you his hollowness and things like that. This is not a neurologist station. Don't worry about it. But if you've picked it up, that's Mark's fear. Have a quick look and see and make sure that you're lifted to the tongue and have a lift inside. Don't just go off the sinosis on the lips. So you've done all that and then I would strongly recommend that you check four lymph nodes in the neck as well as the JVP. So while they're still there, you check your JVP but then ask them to move forward so that you can get your hands behind their neck when you're looking at the lymph nodes, which is a good time to look for scars at the back. And while you're positioning them, make sure that you've moved your arms out. I have a sneak preview to make sure that this is slight, small scars sitting in the axilla or the lower axilla. Now this is that people missed this in the hurry. So this is the time to do it before you go into our sculptation. Absolutely agree with everything you've said so far. And I guess the thing with particularly left-sided scars is you really have to make sure that you are examining the left side of the chest, particularly because you'll be expected to approach the patient from their right side. And you can very easily miss those left-sided, postural lateral thoracotomy scars if they are subtle or they just miss your eye line. So I think that's one thing. I think we've picked it up on the podcast before, particularly talking about left-sided and the fractures, which is obviously in a similar sort of location. But absolutely agree, just absolutely need to be really, really sure that we are just inspecting because missing it will potentially absolutely sabotage your station. You do have another opportunity to come back to it during examination. So this is your first trial at it. So I look for other things. So you've now come to the chest. You're now looking at the chest. So come back to what you've done at inspection from the bedside. So have another look at the trachea, make sure that you've demonstrated, you've done that. Make sure that you look for any other marks on the chest, ready therapy tattoos and co. So let's go through scars now because that's what this particular podcast is about. So where do you think this scars could be? Most leads postural lateral and that's what you'll be looking for. You can occasionally get it right in the center. You can get a natural lateral tracotomy where that can happen. And of course, if you're really lucky, you can get the clamshell tracotomy and then you know where you're going without any trouble because the only reason why they do something like that would be if you've got a long cross run, if you are the indications but that by and large in your exam that's what's going to come. You get that, you know what you're going to do and you start thinking about other things. So that's about scars. There are a few other scars that might be there. The patient may have had a CABG. The patient may have had some cardiac surgery. They may have some bowel repair, something else incidental that may be there. So don't try and fit everything to what your diagnosis is. Just make sure that you've demonstrated it and offered a differential at the time. I have had a patient who had something as completely wrong in the exam. The candidates saw the scar and they went away far away from that. And actually all that scar was some skin tumor that the surgery had repaired and they went off down a rabbit hole or they couldn't come out of. So that's about scars and what to find. This examiner's independently will calibrate for finding. So if it's very subtle, chances are they will give you the benefit of the noun. But that's no excuse. Try and make sure that you've seen most of them. And I think one thing which has come up, well, both in my exams and also colleagues is vat scars, video assisted, thoracoscopy or thoracosomy scars. They can be very subtle. And I guess the question I would like to ask is, where would you typically look? And is there any way of differentiating a vat scars, which of course we know is minimally invasive surgery compared to other, I mean, I'm just thinking, for example, something like you said, like a skin legion or something like that. I think it's difficult to spot. It's usually, literally, and make sure that you've picked it up and say that this could be from a previous procedure. And leave it at that. And then they might ask you what could it be and then you can offer your definition. If you commit to something, make sure that it is absolutely right. And different examiners would react with this differently. So you're trying to prepare yourself. So what you say is take the obvious facts, take what you think is likely to be and then wait. Chances are the examiners will fill that gap. If you start talking and go now one route that you've absolutely determined is what it is, some examiners might just sit back and watch. So my recommendation is stick to what you found, offer some differential and stop. They will come back with a supplemental question, which will direct you to get you, because the examiners out there to find out what you know. They're not really there to find out the depth of your ignorance. And we certainly don't want more reasons to expose that if we are, if we're not confident on the diagnosis. Brilliant. So we've talked about fully inspecting anteriorly and posteriorly. You just need to make a concerted effort to make sure you're doing that. And particularly careful of the patients who have a particularly high BMI, sometimes asking the patients to lift their arms can be helpful, especially if you think there's going to be scars hiding around the back, which may be seen in folds of adipose tissue, etc. And I think whilst it may take time, if it means you have to move the patient, I sit them on the edge of the bed, hang their legs over the edge of the bed, then it does eat up time. But if it's necessary, then I think that could be something that you could consider doing. And then, the next step we would come to, usually in the respiratory examination would be palpation. And there are some signs which we can pick up with palpation. It's important to ensure that the signs which you're going to present to the examiner are all consistent with your findings and your diagnosis. So with your process of palpation, what are the types of things which our candidates should be looking out for? People do this in different ways. And a number of candidates make life really, really difficult for themselves. So here are some top tips for palpation bed to respiratory examination. Firstly, make sure the patients come to work. Two, make sure you've got adequate exposure. So let's start with chest expansion. The number of candidates who miss subtle changes, I could write a book on. And all because they didn't start with the end of expiration. Bake breath in. Let it out completely hold. So you are definitely starting at the end of expiration. Put your hands on the side of the patient and make sure that your thumb isn't sitting right on the chest wall because there will be a drag from the chest wall. So you've got your patient, you've got your position at the end of expiration with your thumbs just quickly up, opposed each other. Then take the best breath of your life and let it out completely. So you will then detect the movement of your thumb against the midline. So you've got a banning and you know if they're both moving equally, if one side is moving less than the other. So that's the first and easiest way to demonstrate expansion. There is no point doing it both sides. So both front and back because if you do it well in the front it's going to be the same at the back but you get two bites as a cherry by doing it at the back. So that's why I would always recommend. So having done that you start lower and then you can go higher, accelerate and make sure that you've detected the expansion there. Apex beat again helps you but you might not be able to feel it. So one of the things I've always used to make sure that you lend them forward to check the apex beat. Shines of right heart strain, a lot of candidates spend a lot of time on this is not going to give you a great deal of value but make sure you've done it. So that's about palpation. I don't recommend doing tactile frementus. It's a waste of time in six minutes but if you want to do it again as two bites as a cherry that's fine. Make sure that all your examination is time to 300 seconds so that you've got yourself a minute at the end to think about what you do and practice it time yourself. I have had candidates not gone to the chest at 180 seconds. It's three minutes gone. They're not even placed their hands in the chest. You're settling on to run out of time. So a word of warning about lobectomies. You might have a scar you determine to say that this is a lobectomy. If there is just one one lobe that's been removed you might find clinically that your expansion is normal. The reason for that is A you're going to miss some subtle signs. You're forgiven. Two the remaining lung may have re expanded. So you won't find a shift of trick here. You may not find an expansion. It doesn't mean the patient hasn't had a lobectomy but if you have no breath sounds at all and the trickier is shifted chances are the entire lung's gone and the number of candidates have told me oh this is a new manectomy. Okay, can you hear some breaths? I guess I can't. So you have to match your findings to what you're going to say and that's one way you can tell between a lobectomy and a new manectomy and the trick as always is to make sure that you have listened properly. I will come to Oscultation again a little bit later but of the warning tips for anybody who's got a lobectomy which is probably in all common surgery than humanectomies will be that it is possible that your patient has at least in your clinical examination a normal expansion. Don't let that put you off a lobectomy. I'll stop there and take any questions. Thanks, Ragley. This is really this is absolute goal for our listeners and one thing I just want to pick you up on you said almost forget about tactile vocal parameters. That is something which has historically been done in memoriam for you know, any year of paces everyone's just like oh yeah, well you've got to do your vestibling pet to illiquid or your tactile vocal parameters. Do you feel that the examiners would expect someone to do that purely for historical purposes and should or would candidates be marked down purely for not including that as a clinical sign? I can't speak for all examiners. What I'm saying is you have got a finite amount of time to do the most valuable investigations to get the most information. If you have a lot of time and if you're just going through the motions that's fine but to me you have to focus on the tests and investigations and the examinations that are going to give you the greatest value and personally I trust my status go a downside more than I trust my fingers but by all means do nobody's going to fail you for doing them. I suspect they're not going to fail you for not doing them as long as you have demonstrated and got the right findings. If you haven't got the findings the great advantage of the tactile vocal parameters is you get as I said before two bites is a cherry okay. Now that's that's my take in it. Other people might disagree but I'm more interested in getting the right answer and personally doing this with the status go gives you a lot more information but I won't stop anybody doing it. I suspect the vast majority of examiners would not mark you down for just tactile vocal parameters as long as you've done vocal resonants. Yeah and I guess one way of sort of compromising that is as you say the probably the best value you're going to get is examining the bag so maybe you could do it on the back forget it on the front if you're running shorter time. Brilliant so then if we move on to osculation which is again this is going to be really really pivotal in this particular examination because we need to actually identify what the underlying diagnosis is for our patient that we suspect has had some lung surgery and hopefully by this point our candidates will have seen a scar and have an idea of some possible options for what surgery has been done but knowing the indication for the surgery is really going to separate the really stand out candidates from those who've just seen that there's a scar and all well I can just say they've had lung surgery. So Raghu what should the listeners be listening out for when they come to osculate the chest in a respiratory station like this? Oskultation this is going to make a break a respiratory station. The first thing I would suggest is make sure that you are actively listening. Now I know that sounds crazy but the number of candidates who got the stats scope on the patient and their mind is still thinking about what their percussion findings were. When you're osculating nothing else to distract you make sure and I've said this before make sure that you've got adequate exposure get them to breathe in and breathe out once or twice maybe in the same side but don't do it too much because many patients will try to help you and by the time you're finished with their examination they have blown off all their carbon dioxide and getting a bit lightheaded. Okay so have a look at what the patient's doing. Listen for breath sounds. Once you've listened for breath sounds then look about added sounds. How they got a ways. How they got new crepitations and if you hear crackles then almost certainly ask them to cough and make sure that they persist post coughing because the examiner is going to ask you that and then try and workout whether it's fine crepitations or if it's more coarse crepitations. It's important for you to get this and this as Sam said before we could start on the back because you get more longer the back than at the front and you've got a lot more time to examine and then come back and look at it in the front. Now we didn't talk much about percussion and we're going to go back to percussion because it is important that you identify what is dull, what is resonant, what is high resonant. I'm going to tell you a few cheats if you like. The first one if you don't know if it is dull or not just percussion the liver any consolidation which is dull will feel like you're percussion the liver okay that's one. If you want to know if something is resonant go to the stomach that kind of feel the body is giving you a ready-reconner to check that's first one. Second one please don't percussion too medially particularly anteriorly because there's a little log in called the heart in the way. So don't waste your time there go more laterally when you're percussion above the clavicle on the clavicle below the clavicle and watch lower down that's it. One two three four and do the same at the back again just capitalize in the way so make sure that you've covered that and listen it is not about whacking the patient from the elbow get your finger movements at the wrist and make sure that you percuss to feel rather than percuss to hear particularly if the patient has some chest wall tenderness whacking the patient might get you a little mark down and skill G so be careful and always ask the patient does your chest somewhere but make sure that you've done both sides and then don't forget to do it in the upper and lower axilla and again that's another chance for you to go back and see if there's some cunning little scar hiding in the axilla and lean over to make sure you looked it on the left side as well as the right side. So you get as many opportunities to recheck your findings without appearing to go over your findings. So that's about examination of the chest itself and I'm sure there's plenty of other things that you want one to do so let your examiners know that you want to do that but while your patient is leading forward just check for sacral edema before you leave the patient you move to the head the foot end of the bed and then just expose the socks and make sure you look to the feet. So all this can be done in 300 seconds and you can rehearse this. So when the examiner says one minute more while you're still having your status quo for whatever is on the patient. Now go through in your head. What are the things going to give? What am I going to say here? What is it that I'm likely to present as my preferred diagnosis? What else am I going to be asked? And think about that so that the moment the six-minute bell is out, you stop, you look up, and you say, "I'm ready." If you finish early, many candidates say, "Yeah, I'm ready, I'm going to go." That's fine, you can do that. Nobody's going to stop you for that. But why? They've given you time to think, use it, and it'll be really, really helpful for you to rehearse some of the answers. So that's where I am in terms of examination, so I'll stop there some and take any questions on that. [Music] Absolutely brilliant. And this part of the presentation, I have to say, for this station is, it's so, I'm going to repeat myself, it's so critical to know exactly what signs you've detected and what you're going to present both as your suggested operation or the reason why they have the surgery as well as the underlying diagnosis. And I guess one of the things which might be helpful to run through briefly is, which we've already sort of covered it in a way, but the combination of signs which are possible and which would be consistent with which types of surgery. And so one of the things you mentioned before is, if you've got breath sounds on that side, it is still possible to eat two have had a low beck to me, but it is not possible to have had a human eck to me, or at least far less likely. And then, I guess the last thing to think about is, has it been a single lung transplant if you have a postural lateral thoracotomy? So if you have lung sounds on that side, for me anyway, the most common thing would be a low beck to me, whether remaining lung has re-expanded, single sided lung transplants. And if there are no, if there's no air entry on that side, then it's more likely to be a new, or a newmanect me, or another reason such as the plural effusion that you've got no air entry or lung sounds at that base. Yeah, so let me just clarify something here, complete absence of breath sounds, and if you're going to say, this is a newmanect me, whereas comparing that with a massive plural effusion, if you are in a dilemma, at this point in your examination, something has gone seriously wrong. All right, so you really need to know whether the percussion findings that you found was dull, or if it's resin, or not. You need to know that and keep it absolutely clear. So when many candidates present at this point, they suddenly say, oh, it might be an effusion. And then the examiner told her, I was like, but your percussion was, and then they get into an absolute test, and then there's something called cranial lingual dissociation. You had to say something, your tongue says something else. So rehearse your answer before you say that. So usually in an examination, there would be a leading. This patient presents with brachlessness, examinous respiratory system, and tell me why or something like that. There will always be a story. So try and answer the question. If you have had surgery, and there's nothing else in terms of findings, the leading might not be what is your diagnosis, because they can't really ask you, because the examiner might say, take me through your findings. Now if you're unable to give a definite absolute cast iron diagnosis, here's a little tip. Say, I will present my findings, and I will try to tie them up with the differential. So that's one way out of, oh my god, I haven't got the foggiest what's going on here. So you start getting the marks for what your findings are, as long as they are accurate, never ever make things up. Errors of commission are frowned upon quite severely, whereas subtle findings that you missed, people might forgive you. So don't make things up. State the findings as you see it. Stop. The examinous might ask you, what do you think is led to it? If they've not asked you anything, and they're just looking blank at you with their blank faces, then you can say, I would like to suggest an underlying cause for why this is happening. And then you can start talking about the differential diagnosis. Remember that if you get a single lung transplant, you're unlikely to have a subparitone lung disease. So if you've got bronchi exercises, if you've got cystic fibrosis, nobody's going to give you a single lung transplant, because within 24 hours, the new lung would be totally infected with that infected lung. So if you're going to say a single lung transplant, you're really talking about things like interstitial lung disease or whatever. So be careful what you're going to say when you start saying these. The commonest pace that you will still get following a low back to me, or even a new monectomy is going to be post malignancy. Okay? Yes, you can get low back to me's and partial removal because of bronchi exercises, because of bleeding and so on and so on and so on. But they're rare. If you're going to play the odd, you say it's more likely to be malignant. So which leads us on to what are the kinds of questions that you might get having presented your findings of some form of surgery and concomitant volume loss. So most examiners at this point would just stop and say, right, why do you think the patient got here? And then you're going to say, oh, it's likely to be surgery due to lung cancer. They then will use this opportunity to go through what you know about the operability. So have an idea in your head. What would determine a patient going in for a curative surgery for lung cancer? So in that case, you're looking at extent to the disease. So what test would you do for that? Does he scan a PET scan? An e-burs, a staging e-burs? You've got to look at lung function. They're going to ask you questions like, how much of lung function would you need? What would you do with the borderline cases? So the old rules used to be you need to have two liters for a new monectomy and a liter and a half for a low back to me and so on. But ultimately, what you really need to convince examiner is that having taken away X number of segments out of the patient, what would your predicted host operative lung function look like? And is that going to be enough for the patient to live? And that's the kind of thing you want to say. But these days, you can't talk talking about cardiopulmonary excess testing and other assessments. But if you're being asked about CPACs, you're doing marvellously. But don't worry about it. But increasingly, examiners will start asking you about what is likely to happen during or immediately after the operation. And you might argue that's unfair because that is really a surgical issue. But the reason they're testing you is not to check whether you know what the surgical complications are. Why they're testing you for these kind of immediate and late complications is when you are having that conversation with the patient before you send them to Mr X at hospital. Why are you able to describe them? What are the things that might go wrong? Whether it's bleeding, whether it's collapse, whether it's infection, but injury, whatever. So you need to know and have an idea of how to answer that question so that you can demonstrate to the examiners that you are able to give the patient enough information to make an informed choice about surgery as an option. It will not be your call at I am stage one trainee, but you need to be able to demonstrate that you have the background underlying knowledge of what is likely to happen before during and after. As I said, by this time the 10 minute bell will go and you'll be saved by the bell. But have it in case you're doing very well and they start asking questions. Thanks, Ragged. This is excellent, excellent stuff. And I guess my main thing would be with with a question like that. If you are short for time, rather than trying to spill a minute and a half long speech on the complications of lung surgery, have you seen or know of any examples of ways that you can concisely succinctly just sum up a nice little 30 second package of possible complications of lung surgery before the bell goes just so you can You can make that demonstration that you've just described. The first suggestion is answer the question that has asked of you. It is unlikely that the examiner is going to say, "What are the complications of lung surgery?" They're not going to give you as broad because the examiner is knowing. If they do, then all you have to do is say, "Well, there are a number of complications, some of them immediate post-operatives, some of them later on, and then you break that down into your surgical sieve. Could this be bleeding? Could it be infection? Could it be?" What happens in the middle of the night when there's a collapse? Sometimes what happens is you can get mucus, mucus, a plugging, and things like that. So they might say that post-operative, these are the things that might happen. So you might want to class what they're looking for is your ability to compartmentalize a huge amount of information, to present it in a way that is compatible with the time you've got, but more importantly, try not to drift into elaborate detail because remember that what they're testing is whether you can say that to a patient. So the patient asks, "What do you think the complications are?" And you've got two minutes before their times up. What are you going to say? Just to take yourself a wave from the exam, and put yourself down in your clinics, and your patients in front of you, what are you going to tell them? Now do that, and you can't go far wrong. And it's so perfectly okay to say, "I will defer to the surgeons who will go through this in a little more detail with you." But these are the things that I would expect. Or another way, a clever way to get around this is to say that, "I would suggest you ask the surgeons these questions, what is the likelihood of bleeding, what is the likelihood of may having respiratory failure, what is the likelihood of having any compromise or injury to where it is always?" So you might turn it around like that to say, "I might ask the patient to warm them, that these are the things they should write down and ask the surgeon when they go to season." So that way you've got yourself off the hook, you're still answered, and you've become the patient's advocate. Take, take, take. And I guess the other thing which goes in with that is knowing your limits as an IMT level doctor, and obviously that's part of Paces is you're not the fountain of all knowledge, but you know where to find that information if you need to. Yeah. Or you know a person who does. So I haven't, well, I mean, we've pretty much made it to the end, I think, and we're 40, we're 40-ish minutes in. So I'm happy to sort of close, close there if you're happy, value, unless there's, is there anything else you think about this station of lung surgery that we haven't maybe covered in as much detail yet so that you think is worth mentioning. Not about lung surgery itself, but in this station I would expect the vast majority of trainees to get it right. So this is easy marks, so don't mess it up by making things up. It's all my advises. This is just low-hanging fruit that you can go confidently into the abdominal station. Yeah, absolutely. And that's, we'd mentioned it on the podcast before that with these, the really common ones, you know, the peripheral neuropathy, the aortic stenosis, the valve replacement, the intitial lung disease, the, and the lung surgery, these are the classic cases of Paces and getting it wrong is really not an option and you should, by the time you come around to sit your exam, hopefully, have seen patients in who have these types of conditions. So I think that's pretty much all we have time for for this episode of the of the Pre Paces podcast. That only leaves us to say a massive thank you to Dr. Arant Krishnan Raguram. Ragur has been a real delight having you on the podcast today. My pleasure. And listen as that is the end of another show. So please don't forget to like, follow and subscribe to the podcast wherever you get your podcasts. We love to hear from you. So give us a shout on our Twitter. It's @prepacespodcast. And if you really want to go above beyond and support the show directly with a voluntary pay what you can donation, it's bimerecoffee.com/prepacespodcast. But for now, we are just about out of time. Thank you for listening and we will see you next time on the Pre Paces podcast. [Music]