Greetings and welcome to the Introduction to Astronomy. In this lecture, we are going to talk about some more of the debris in the Solar System, including the Kuiper Belt, and one object within that, named Arakoth, which is one of the few objects that has been explored that far out in the Solar System. So, let's go ahead and look at the Kuiper Belt, and we talked about the Kuiper Belt before, the objects orbiting out beyond Neptune. Sometimes they're also called trans-Neptunian objects, anything out beyond Neptune or TNOs. And there are also some objects called centaurs, which orbits near the outer planets, so we have a couple different types of objects here that we look at. The first of these kind of things that was discovered was Pluto. So, Pluto was discovered in 1930, Chiron was discovered in 1977, which orbits between Saturn and Uranus, and we see the orbit here of Chiron in there, actually going in between, inside the orbit of Saturn and slightly outside the orbit of Uranus. And then we had Folas discovered in 1992. We now know of thousands of these objects, so there's a lot of them that are known now that were not just not that long ago. Now, what are the largest ones of these? Well, we've already mentioned the dwarf planets. We've talked about some of those. The four dwarf planets are the largest trans-Neptunian objects, and that includes Pluto, Eris, Makemake, and Homea. Those are the ones that are classified as dwarf planets. There's a few others that may meet the criteria and may eventually be classified as dwarf planets we see here as well. However, Pluto is the only large object of these that has been explored so far. And here we see Pluto as seen by the New Horizon spacecraft when it flew by in July of 2015. Now, that was part of the New Horizons mission, and the New Horizons mission was launched in 2006, and it was a nine-year journey to Pluto. However, the mission was also extended. So the idea was now that we've explored Pluto, is there any other object in the area that's on the trajectory that the craft is taking that will allow it to be able to make another visit now that the craft is there. And we see that here that the path was taken from Earth out in towards toward Pluto, and then New Horizons now being right here and passed by Eracoth, which was another object. It was known as 2014 MU69 before it was formally named. So interestingly, you'll note that it was launched in 2006. We didn't even know about Eracoth until several years later while this was mission was ongoing. So we'd happened to have discovered it, and it happened to be in the right positioning for New Horizons to be able to make a second visit. Now, what do we know about this object? Well, we knew very little about it before because it was just a small blip of light, and you'll see it here, and you can watch as this animation takes you in through the New Horizons as it heads toward this object, and we'll continue to head in, and you can see the object slowly moving there now. And as we get closer and closer, you'll see it start to take some kind of shape as we're able to see some more detail. And you'll see that now it starts to have some detail. And we can see the object, and there is Eracoth. It is very interesting. It was flown by on January 1st of 2019, and was, again, the second object out in the Kuiper Belt and the first small object out there to be explored. It was found to have two lobes. So it was multi-lobed. It was not just one piece. It was two. So there was a larger piece that was about 21 kilometers. The smaller, about 15.4 kilometers. It is what we consider to be a contact binary. So it did not form like this with these two lobes, but two separate objects formed, which then hit each other gently and kind of stuck together. And here's how we may think it may have formed, and we can take a look at that. Here, four and a half billion years ago, several objects were forming. Eventually, they collected other material. Two large bodies remained. They were in a slightly decaying orbit, got closer and closer, and eventually stuck together. And they remain that way to this day. That's also interesting. They are small, but they also have a flattened shape. So most things we look at are spherical. These are actually very flattened. So it's interesting, but we really don't know a whole lot about the objects out in the Kuiper Belt. We have to study more of them in order to be able to study them and get any kind of good statistical studies as to whether Aracoth is just an unusual object or whether they're all like this and help us get an understanding of that part of the solar system. So we've explored far more in the asteroid belt, much closer to us. We've had a number of asteroids visited, but we've explored far less out in the Kuiper Belt and are still learning much about what happens there. So let's go ahead and finish up with our summary. And what we've looked at, we looked at the Kuiper Belt as a collection of many objects out beyond Neptune. Some of these Kuiper Belt objects has been classified as dwarf planets. And New Horizons visited two of these. It visited Pluto in 2015 and then Aracoth in 2019. So that concludes this lecture on the Kuiper Belt and Aracoth. We'll be back again next time for another topic in astronomy. So until then, have a great day, everyone. And I will see you in class.


Welcome to JSA TV Europe together with the green data movement for these courses live event focused on European Digital Infrastructure Sustainability. I'm Dromarch Lim and joining me today is Steve Brown, CEO of the leading head hunter recruiter in the data center and cloud infrastructure sectors worldwide, data center people. Steve, welcome on JSA. I guess the only things that you know better than data centers are the people that work in them. Your old tagline which has always resonated very well. Talking about talents, I mean when we look at the data center space we're always talking about shortages and how things are going but there's so much demand but we can't find people etc and we're going to get into it but what what is the role of sustainability in the data center talent space today? So thanks for the introduction Jao, thank you for the invite that there are two aspects to this as we all know sustainability has become central to data center development and operations. This has come about as a result of ever-increasing awareness of the the energy and environmental impact that data centers have as well as a more eco-friendly approach being demanded by customers especially the big corporations that now take sustainability extremely seriously. So in turn this has had a consequential impact on hiring with roles being created to focus specifically on sustainability. We as a head hunter and recruiter first saw sustainability being highlighted back in the mid 2010s around 2014-2015 we noticed it coming up initially in electrical and mechanical design type roles where clients would when we were discussing a search brief would express to us a desire to hire engineering talent that had some exposure to to sustainability practices in their design work. Now things have developed at pace since then and we are seeing roles dedicated specifically to the sustainability subject because managing sustainability in a data center requires a lot of specialist expertise. So we've handled in the last few years we've handled searches around energy procurement, energy management, environmental compliance and sustainability management where the remit is to lead on the wider sustainability piece at organizational level. We're also seeing specialist roles being created particularly by the larger operators where those roles focus on very specific aspects of sustainability such as heat export. With the smaller to medium sized operators then sustainability particularly at the more senior level operational management roles sustainability is a part of the responsibilities of the role and we the searches that we take on we're being instructed to hunt for candidates that can take on a position where sustainability is a part of the role and candidates that have experience around the sustainability piece. I'm also seeing sustainability coming up in other areas such as sales and marketing. Just the other day I was instructed by an operator client on a search for a head of sales and the client made the comment that the person that they are hiring should have sufficient knowledge to be able to discuss topics such as heat reuse with prospective clients particularly prospective hyperscale clients. So that's that's one angle to it. The the other side of sustainability in in hiring is about making hiring processes hiring practices more sustainable. So we all know that there's a huge shortage of skilled data center talent. Across the industry everyone is chasing the same people. That's pushing up salaries which to some extent is is good news for the candidates. Candidates need to be careful they don't price themselves out of the market but it's not sustainable for the companies that are doing the hiring. So there's there's a need to devise more sustainable hiring practices. There's there's a lot of talk now about bringing data center operations engineers in from other mission critical industries not just the obvious ones such as the military nuclear or the offshore industries but any industry where downtime can be caused by mechanical or electrical system failure. That's the place where we need to go hunting for the engineers that the data center industry needs. So resolving the skills shortage is is a key to sustainability to keep stealing from your competitors is not it's just not sustainable but then you've got to look at how you make once you've got your people you've got to look at how you make their employment more sustainable. And for that for me that's about making sure that the employee is is trained that they develop the skills to enable them to undertake their role in in the most sustainable way. It's also about providing the the job challenge the satisfaction the learning the progression all of the things that we look for as an integral part to enjoying our work and that will make for a longer term opportunity for the individual that will cut down on on staff turnover and in turn will make that the the the whole environment much more sustainable. Get all that right and that's no mean feat and you're a long way to having a set of really sustainable hiring and employment practices in place. It is a combination of factors which which you've described very well from the pre-hiring to the hiring to the keeping the hire in the business and I think your point arounds keep stealing from competitors it's no longer sustainable I think that's very true and that's something that we're seeing a lot more especially in newer markets where new companies are emerging from from the ground up where the where CEOs are literally people they used to work in energy companies or financial firms or deal with energy form within a financial firm. It's going to be a shift in skills that we are seeing in new businesses popping up in newer markets across Europe but before we go into those markets those markets are always very interesting of course we mentioned how sustainability is changing talent recruitment but what would you say are still the main challenges within recruitment in the space today in a more general term not just within sustainable sustainability? That's an interesting question we've we we've noticed that in the past 15 to 18 months the counter offers have become much much more prevalent so pre-covid you would see this at more senior levels and we've we've got a we've we've got techniques that we use to handle this with a candidate at the point when they're they're going into to resign from their their current role but there's two things in the past 15 months or so that we've picked up on with regard specifically with regard to counter offers firstly it's the fact that it's not happening now just at the more senior levels it's happening at all levels so we're having to if you like council the the companies that we work with on hiring to prepare themselves for for this the other thing that we've noticed about it that pre-covid the counter offer might be perhaps in the region of of a 10 to 15 increase on the individual's salary now it it's gone higher 20 to 25 percent and depending on the level of individual there can be sweeteners thrown in such as equity and and that's that that's that's making the hiring process a lot more challenging that that's that's really the the the number one quite apart from all the issues around finding the talent in the first place and encouraging them to sit down at the table and engage in discussion about a new opportunity that the battle isn't over by any means we are just at the beginning of this battle exactly yes yes and and perhaps we'll never have an end to it either because it's this evolving thing skills are an evolving thing it's not it's not an A to Z race it's an A to the infinite because skills will have to change as the market and the business changes as well over the next years and decades to ensure the future we sorry and that's a good point it's it's not just about the skills changing it's about companies thinking laterally about the type of skills that are relevant to a particular role and also where they're going to find those skills and that's that's where we can help we can provide advice and guidance we'll also we'll sit with our clients and we'll challenge them they'll hand us a job description and it'll have perhaps eight or ten bullet points on it about the skills and experience they they want so we'll work through that is that really necessary do you need ten years of that what about this and and we'll encourage them to if you like re-engineer reshape the job description given our knowledge of the marketplace and and how successful we think they're going to be in in attracting talent into that specific position and I think there's another very good point because sometimes businesses are so stuck in the old ways and you just copy and paste there's no no need for change when there is a lot of need for change and actually what you just said it's not applicable just to recruitment and job descriptions there's a lot of other aspects of the business that happen like that from marketing to other elements of the company there's so many so many times more often than not it's just copy and paste from previous days and it's no longer free for purpose but I was just going to ask you sorry now go I was going to ask you because we've already kind of touched on the the the newer markets as well I just wanted to kind of gather your the demand that you're getting from newer markets let's put it that way are you seeing a lot more a lot more demand from tier one tier two tier three regions across Europe we are for sure so in terms of the tier one markets what we've noticed particularly this year perhaps perhaps it started towards the end of last year as the embargo in in Amsterdam was lifted we've noticed a lot more activity in the Netherlands in terms of our our search work in terms of the tier two markets then it's Spain it's Portugal it's Italy it's also Eastern Europe and one of the things that we've noticed there is that pre-covid those particular locations it was it was a lot easier for us to to get into those locations target talent and convince them pretty easily about an opportunity that could involve relocation to to say the Netherlands to Germany to the Nordics now post-covid where those particular markets are seeing real growth it's becoming more difficult to convince target candidates that they should be thinking about not just about a move but a relocation to to a different country we've we've noticed so that's Europe we've we've noticed increasing activity in the Middle East Saudi Arabia also in the North Africa certainly discussions from people looking to get into markets the North African market and and Egypt in the Americas it's it's Canada Mexico and Chile where if you could define them as as tier two markets and then in APAC it's it's been Indonesia Malaysia and and the Philippines so so this issue of newer markets coming up then it's very much a global thing it's it's happening it's happening pretty much everywhere which is exciting I mean as you were mentioning the different countries in my head was like yep this company that company that company that company because every market is so active there's so many new names going on going into those places that's very easy to think that they need like 100 200 300 people just out of the blue in any of those regions and that's per company as well so I'm sure it's very busy that isn't the people and then speaking of which I mean so how are you going to cope with all that demand what's the plan for the next 12 18 months around that is of talents recruitment so we as a business we're we're we're doing one of the things we're doing is is investing in training to make sure that our recruitment research and delivery teams really understand the the industry that is that's absolutely key we we want to be more than than just a a recruitment company we we we really want to to be seen as a niche data center recruitment company but but where the people that you engage with really get what your business involves they understand the type of roles that you're hiring into or as a candidate they understand the type of the type of job that that you undertake and the type of moves that might interest you so we we're taking on so that's one particular aspect the training most of our work is undertaken on an exclusive basis and and that means that there's pressure on us as a business to deliver but it also means that for the client we're able to utilize techniques that increase the likelihood of us getting the so-called passive candidates to the table to discuss opportunities rather than becoming embroiled in a a cv race which is what happens when companies instruct multiple recruiters on a requirement that actually doesn't benefit the hiring company and it most certainly doesn't benefit the candidates so we're also there's there's work going on we've got planned over the next 12 to 18 months work around if you like constantly improving our business model so Dave Brailsford referred to it as marginal gains that's that's something we're very much focused on and and it's about making sure that we've got the capability as a business to meet the demand for our services and and and watching with interest to see which are the markets we're going to be asked to recruit into next yeah well speaking of next i was going to ask if one of our viewers wants to to to increase your workload pile how can they get in touch so through LinkedIn otherwise datacenterpeople.com or they can email me steve.brown at datacenterpeople.com okay sounds good well Steve as always is a pleasure speaking to you i think what's happening is that it's in the space as a as a whole is always very exciting to to get through but then when we go into niche areas of the the sector like this one in around recruitment and skills which is so so paramount to the success of the long-term success of the entire sector i think it's always very interesting so thank you so much for coming on board as for you watching at home thinking for tuning into jsa tv live don't forget to check our social channels for more content and until next time happy networking thanks


All right, so we're going to discuss Vascular and I'll ask you questions first and then my colleague will ask you some more questions. Okay, is that fine? Now, have you ever managed a patient with a limb that comes in that is obviously necrotic and dead? Can you just run me through the causes of necrotic low limbs? So by definition necrosis refers to a tissue that is no longer viable. The causes for necrotic limbs can be classified into infective causes and then purely vascular non-infective or infective and non-infective. Going down the non-infective route, causes can be classified into thrombos and emboli. Under your emboli, there are different causes for your emboli so they can be from the, they can have cardiac source, they can have aneurysmal source. Okay, that's that limb done. In terms of your thrombus, they can be an existing thrombus that caused obstruction of the blood supply to the limb. It can be something that's propagating, moving on to your infectious causes. Infectious causes causing necrotic limb would really be your very severe infections like your neck fash rather than your superficial tissue infections. Now you mentioned obviously arterial causes, wouldn't you suggest that which is a vascular compromise, a blood supply compromise other than just thrombos and emboli, certainly there are other causes of blood not flowing to them causing a dead limb. Yes, you could have trauma. How would trauma need to a dead limb? So if you've got occlusion of your arterial supply, completed occlusion of your arterial supply secondary to trauma, you could result in a dead limb. From what mechanisms? Penetrating trauma, blood trauma could do it, so for example crush injuries, compartment syndrome. There's compartment syndrome, tell me a bit more about compartment syndrome leading to a dead limb. Is that sitting here a large percentage of patients that you left out of your causes then? Compatiment syndrome by definition refers to a condition in which the pressures within a particular osteo-fascial compartment exceed the pressure required for cochleary flow to supply the tissue with oxygen and nutrients and to remove the byproducts. How compartment syndrome results in a dead limb would be as follows. So initially clinical presentation patients would present with pain of the limb, pain swelling, they would complain of pain swelling edema on examination, the limb would be tender, the compartment might maybe tense. Can I ask you about the pathogenesis, pathophysiology of compartment syndrome and how that leads to a dead limb. So what happens is in compartment syndrome, if you've got, for example, gg crush injury, you've got damage to your muscle which results in edema, that the edema in the compartment results in the rise in the compartmental pressure which reduces the, once that pressure exceeds the pressure, the pressure required for cochleary flow to occur, there's no longer any flow, with no flow there's no oxygen supplying your tissue resulting in, ultimately a dead limb. Okay, you mentioned the infective causes of a dead limb, what a common cause you said necrotizing fasciitis, but I think it's a bit more than that. What infective causes do you have seen that has led to a dead limb? What was the underlying pathophysiology? Was it purely the infection, was there spider bite that led to so much infection that the limb was actually non salvageable? How does infection lead to, or what role does infection play in the dead limb? Is that a primary thing or do you think it's a secondary thing? So infection or toxins, for example spider bites or snake bites would result in a dead limb by means of the, for example compartment syndrome. Sorry, that's the only pathogenesis I can think of for both spider bites. What is the most common infected limb that you've ever seen that required amputation because the limb was un salvageable? A diabetic foot. A diabetic foot, so what's the pathogenesis behind the diabetic dead limb? There are multiple factors which play a role in resulting in necrotic eliminate in a diabetic patient. There are microvascular, macrovascular and neurological parts which contribute to it. So patients who are diabetic, firstly they already have a compromised supply. So when they have any source of infection which, sorry this is not an organised one to begin again. So the pathogenesis of a diabetic patient and a dead limb. Any insult to a diabetic patient's foot, be it due to trauma or a snake bite or rather any trauma or a world result doesn't heal as normally because the patient's got firstly pure blood flow. No, come on. What vascular pathophysiology does a diabetic have? So basically poly control diabetics have increased blood glucose leading to glycosylated hemoglobin and glycosylated other proteins also glycosylates which result in reduced or rather increased stiffness if you will of the blood vessel or capillary wall. Leading to reduced blood supply to the tissue. Ok, there are many factors in a diabetic which would result in a dead limb. Ok, but that certainly is the vascular issue as far as there is neurological things as well but vascular. Now you've got the patient with this diabetic foot. What criteria, what are all the aspects that you have to consider before deciding that this can be treated conservatively or requires immediate imputation? What are the criteria that you think about? So the criteria we think about is the patient's baseline and then the actual infection or presenting problem at hand. In terms of the patient's baseline, how is the patient's diabetic control, usually does the patient have any other comorbid factors, is the patient accounted for surgery, what is the patient's activities of daily living? In terms of the actual presenting problems of the dead or infected foot, I would want to assess the degree of the problem. So is it just a superficial infection that will be treated with antibiotics? Is it something that requires minimal debridement? Is it something that I've assessed on X-ray, it involves the bone and requires more extensive debridement, possibly amputation? That's how I would go about deciding. You've lost me a bit in as much as the specifics are concerned. If we just look at the clinical examination of the limb itself, what factors in the clinical examination would you consider to decide that this limb is salvageable? So basically assessing viability of the limb. I would look at the, so again the extent of the infection. I would assess the pulse status, assess sensation, see the degree of edema or erasema surrounding the infection. I would also, well, no, I would also ask the patient about just often patients with diabetes have other comorbid diseases. So often those smokers have atherosclerosis and would have peripheral vascular disease. So that would affect my management as well. You mentioned that this poorly controlled, my last question, poorly controlled diabetes leading to these vascular, micro vascular changes. Perhaps calcifications in the wall, et cetera, you mentioned the stiffness. Is the direct correlation with poor control versus how much vascular changes there are? Or can a well controlled diabetic also present with peripheral vascular disease and the complications of the diabetes? Is it purely the poor control? So there are two issues at hand, as I understand it. One, you can have a patient who is a diabetic only and that patient can have micro vascular complications secondary to their diabetes. Then you can have a patient who has two concurrent pathologies running so they can be diabetic. And they can also have peripheral vascular disease secondary to either the, or combination of factors, the smoking or the... My question really pertains to the fact, is this the poor control that leads to diabetic peripheral vascular disease? Or is it the disease of diabetics even if they are well controlled? You seem to have made that distinction, is that so? Is it direct correlation? Do you think? I don't have a question. Alright, my colleague will ask you a few questions. Now we needn't go as long as I did, but I just want to give you thinking your own question. Yes, it would be questions that might be pertinent in your mind. Questions that you would like answered or stuff that you've read. In terms of assessing the limits of whether you will amputate them up, I think you've done a very good job of elaborating on local sort of clinical features that would suggest a limb that needed to be amputated. Are there any sort of systemic features that you might focus on where you might sit there and think that this patient may require an amputation, if so would you elaborate a little bit on that? What I'm trying to say is a localized sepsis. The things you've discussed so far seem to pertain to a localized sepsis. Obviously that is not always the case in the way that diabetic horses and diabetic footsepsis presents. There are other sort of instances where you would strongly consider an amputation in terms of... Oh I see, okay. So you're basically alluding to the DKA of patients presented in severe derange hypoglycemic states. Not only DKA, but in terms of not just localized sepsis, but I'm talking more systemic sepsis. So according to the surviving sepsis guidelines, they've got many campaign bundles which basically guide our management in these cases. And one of the very important points that are brought out is that the source control. So if a patient came to me whether they were diabetic or not and they had systemic sepsis and we identified a source and the source was a limb that could be drained, divided or was so extensive in the initial assessment that required amputation, yes. So I suppose the answer would be that I would be guided by the surviving sepsis campaign which uses certain campaign bundles to guide our management, one of which includes source control. Others include illegal directed therapy, optimising the patient for theatre, ensuring patients often with diabetes have other comorbidities and we would optimise the hemoglobin to above 10. Other endpoints that we would aim for are a lactate level of below four. If not, you would administer fluid, repeat the lactate. Even that you would also measure CVP, I don't want to mention CVPomage. We would also aim for CVP between 8 and 12. I think we've done a good job in terms of covering the septic side of things. Obviously we've said before that not all ischemic legs require amputation. In another vein of assessing limbs, can you think of any traumatic related injuries that may require some sort of criteria to assist whether their limb needs to be amputated or not? And if so, then maybe perhaps elaborate on that for us. So something that comes to mind of patients with acute or severe trauma. So gosh trauma due to any mechanisms, train accidents, accidents related to work. So patients coming with severely mangled fingers or limbs for that matter. In terms of assessing the principles are pretty much the same. The question, well actually, there are two things that I would consider. One, the patient and under the patient would be the patient's comorbidities, et cetera. Not safety, ability to be operated on and then the actual problem. So the mangled limb is the pulse, how far does the tissue damage, how extensive is the bony involvement. In addition to that, so like local factors, when I say local hospital related, what facilities do we have, what are our surgeons capabilities, are we able to re-anestimise certain vessels or is it a case of we are doing a bit of damage control because we are poorly resourced. So that's not just patient factors that I would take into account. That wasn't recorded.  Okay, apologies for that. My colleague is now going to ask you some questions. So we're going to be in keeping with the theme of vascular. How does the patient with, you mentioned acute and chronic causes of gangrene. Can you tell me how a patient with an acute cause of gangrene of the foot would present of the toe? In most of the cases that I have encountered is that most of these patients are elderly patients and most of them prefer vascular disease and on top of that they get acute presentation on the basis that they might have other comorbids and mainly patients with cardiovascular problems they can get emboli. Like patients with AF, they get emboli that goes down to the already diseased narrowed vessels in the preference and thus causing acute presentation of the chronic patient that is known with peripheral vascular disease. Okay, but what do these patients come in complaining of? Mainly presentations of these patients mainly acute presentations though they are known with chronic vascular disease they might have called claudications before that's a history that has been known they might have been following up in the clinic with their claudication but this presentation that presents now is an acute presentation that presents with pain complaining of sudden onset of pain it depends on how long the pain has been patients may present with parasitises as well they can also present with motor function loss of motor function as well on examinations so from the history you can get that patients have cardiovascular disease or they might be known with other vascular problems like patients who are having aneurysm they might have aneurysm above their level Okay, let's get you a little bit away from the history because you've covered that, I'm happy that you've covered it adequately but coming down to when you examine your patient now what do you see? Do your patients complain, they've come in, they've said the pain started, they've had two days the pain just won't go away What do they do? You're examining the patient now, what do you find? Okay, on examination of the patient you need to also initially inspect the limb looking on inspection of the limb you can see the limb is pale the limb is pale he can't move the limb or he can't move the limb but with pain this is some of the thing that you can see on inspection on examination the limb will be very cold compared to the other limb function wise patient may not be able to dorsiflex the limb that's also one of your examination that may give you now the criteria of whether you should categorize them as a fourth classification whether they are class one, class two, class three Tell me about the Rutherford classification Rutherford classification is classification of the presentation of the patient with an acute presentation of acute limb schemia and it's divided into Rutherford one, two, three and two and two B and Rutherford three Rutherford three being a dead limb that is unsalvegable and patient may need amputation depending on how unsalvegable the limb is Rutherford one is still a salvageable limb where patients present with parastasis pain but still they have motor function Rutherford two, two A still they can have motor function but the sensor is lost Rutherford two B there is no function where you need this patient to do a fascia to man see whether there is any muscles that are contracting or not otherwise they become better for three no dead amputation ok now I'm sure you've seen patients with necrotic dead limbs before ok so a patient comes in is obviously a non viable limb what are the causes that run through your mind as to reasons for a necrotic limb unsalvegable limb let's stick with the lower limb I think two broad categories depending on the patient would be your trauma patient that has an unsalvegable necrotic limb for reasons ascribed to trauma and then you have a patient that has underlying chronic disease specifically vascular disease that could be the cause of this so depending on your etiology or your underlying cause that would then definitely determine your project, your management of this patient can you be more specific about these groups now that you've described to us so in the trauma patient causes that I could immediately think of is the threat in them in terms of where you have a mangled limb you have underlying fractures and you have a patient that's sitting that had an untreated compartment syndrome where your blood flow was compromised you're saying a deep necrotic limb so this is a patient that's presenting quite late trauma is an underlying etiology but what happened is compartment syndrome et cetera and that's the cause of your limb obvious vascular injury and then you're when you're looking at your chronic disease patients is your vascular path your peripheral vascular disease which can be again this is a deep non-viber limb can further subdivide it into a patient with wet gangrenas limb or dry gangrenas limb in your dry gangrene you're thinking more chronic vasculopaths in your wet gangrene you're more thinking of your diabetics with nephropathic feet et cetera which can lead to this problem is there a patient that can have absolutely healthy beautiful arteries and present with a dead limb noe external trauma involved you've mentioned the diseased arterial system is there a patient that can present with a dead limb and they have beautifully normal peripheral arteries at this patients with deep venous complication this is one of the rare more serious complications of deep venous thrombosis would be your Surinia dolens over sorry I can't remember the exact amount or more severe complications of your deep venous thrombosis where your venous system is the underlying etiology of other common causes of nephropathic limb with normal peripheral arteries then complicated venous disease I suppose we've got severe obstructive disease noe it's a normal healthy artery yet but external compression I suppose you have to take external compression but more common than that you've mentioned the thrombosis what's the mechanism of embolas and how does an embolas cause a healthy artery to occur I use the term healthy loosely here these patients with the embola inherently have some underlying pathology that might lead to them having peripheral vascular disease but let's say early in the disease and they are healthy otherwise so how does the embola cause this occlusion where did the embola occur so one of the questions when you see patients with embola a phenomenon is that once again to determine the underlying etiology most commonly patients that you two big classes that you need to speak to mind would be patients with valvular heart disease and then patients your chronic intervenous gut users also commonly could present with embolic phenomenon so these patients need to be thoroughly investigated but that's just embola from hematological origin embola could also be infective and we also can get air embola you mentioned that beta is a very impassing what is the mechanism what is the pathophysiology and diabetics leading to peripheral vascular disease and unsalvageable limbs let me down the mechanism so the problem with diabetes is especially longstanding poorly controlled diabetes is end organ damage and besides the eyes and the kidney and the heart part of the peripheral problems that you deal with is peripheral neuropathies that these patients develop meaning that they've got atrophic changes peripherally to their feet and sometimes even hands where I think the most common these patients lose sensation in their feet they often injure themselves without knowing and because of compromised immunity they are already at increased risk for susceptibility to infection and decrease ability to fight it off so not only do they now have injuries that can't be attended to and they're not aware of but they also have underlying vulnerability to the sepsis and and then there is the micro vascular disease in itself which compromise tissue healing and wound healing so you see a patient with office diabetic foot sepsis what are the thoughts that run through your mind to decide whether this patient needs immediate ablation or they can be treated conservatively what are all the questions that are in your mind to help to guide you in making this decision okay so obviously you look would start by looking at the patient as a whole in general let's call it the eyeball test not that's maybe a bad term to wish but systemically how your patient is looking is this is there any signs of systemic sepsis which ofc would be immediate indication for sepsis control which was often would be ablation then if you look at the so that's a general part of the general assessment for me would also be your patient's glucose control that might not necessarily influence where when you would ablate the patient especially if the sepsis involved but it would give you a good indication as to how your post operative management of this patient might look in terms of the local sepsis first of all you need to assess the sepsis is it wet or dry dry not so common in your diabetics is it what's the level of spread is there pockets of these pockets of pus we need to x-ray is there any signs of osteitis boiling involvement gas in the soft tissue the surrounding cellulitis what is there the pattern of spread you also going to assess your vasculature which in diabetics not often easy to assess accurately especially if in acute sepsis patients are often edematous cellulitis difficult to assess you going to have to do Dopplers and discuss with your patient and plan the procedure which often might be a stage procedure so getting rid of the sepsis what would be the reason to be a stage procedure is to definitive amputation as your primary procedure how do you make that distinction well I think once again you have to look at your patient in general patient that's systemically septic where this is a case of sepsis control you would want to do the quickest procedure possible to get rid of the sepsis which most often is not a definitive procedure a TMA or a thrunie amputation quick less anesthetic time it's a resuscitated procedure in my mind if that's not the case it's a bit more at local factors when there is obvious pockets of pus or bone involvement but there is also spreading cellulitis where you can reason that you could get rid of the overt sepsis and pus and attempt in order to preserve some functionality treat the more superficial sepsis like the cellulitis with good broad spectrum antibiotics you know that would be one of the my colleagues can do ask you just a few short questions okay you're calling casualty to see a patient that presented a acute painful limb what are you approaching so once again a acute painful limb whether this is a patient with a history of trauma or whether this is a patient who has just acutely presented with this problem without necessarily a history who definitely you know influence how I would manage the patient should this be a patient that has had a history of trauma whether it be soft tissue or bony in representing the patient is a patient that is known with chronic vascular disease vascular disease would be a threatened limb so immediate assessment of the patient would be a full systematic evaluation of the patient in terms of history what is his current status is what do you mean by current status is it just a limb that's a problem or is this already a systemic problem in terms of the limb specifically let's go there is it just what exactly is the patient presenting with is it just a painful limb is it absent pulses is there already signs or evidence of tissue loss what is the extent of the vascular disease vascular disease is indeed what we are dealing with so there is various investigations that I could do to aid me in that this patient present in casualty doesn't have any tissue loss but he had been complaining about short distance colloadication in our presence with an acute onset of pain by your approach okay so what you are thinking is a acutely threatened limb here so once again it would be that this patient sounds as if he would be a candidate for a re-vascularisation procedure most important is to determine the level of disease and to then adequately prepare the patient for theatre so part of determining the level of disease would be a paraclinical examination is all these patients are going to go to theatre or you have a procedure where you can no you could have open vascular procedures and then you could have endovascular procedures as well which you can choose select certain patients for okay so clinical examination of the patient feeling impulsives testing sensation basically putting the patient in a rather scoring system might aid you in aids of special investigations like Doppler hand held Doppler what is that about classification can you tell us about rather for the classification classification 1 to 4 basically looks at pulse status and tissue loss unfortunately I can't remember the detail of the classification okay thank you okay so welcome to this oral examination I'm going to ask you a few questions and my colleague will take over from that okay I take for granted the fact that you've seen the endocrotic limbs before lower limbs I have yes okay after all of that interruption there are various causes for necrotic low limbs for necrotic legs what are the thoughts that run through your mind as to causes of non viable limbs that need oblation is this an acute setting any setting so from a broad category I look at in terms of timing or duration so acute ischemia and more chronic progressive things that have happened with acute break that down further into trauma traumatic causes and then vascular causes as well arterial venus thrombotic and embolic phenomena traumatic and further be broken broken down into physical trauma as well as toxins and bites and of course those sorts of things you could get this is by no means a comprehensive list but some way of breaking it down and then chronic forms very much in peripheral vascular disease would be progressive chronic form of ischemia lemoschemia and if I further differentiate further causes that would be a broad category let's go down you start with the acute very interestingly mention toxins as a cause of necrotic non viable limbs and from that I presume you mean exogenous or extrinsic toxins leading to non viable limbs have you got some more specific examples for that and what the pathogenesis is from that initial insult to the situation of the non viable limb so the traumatic toxin or it could be infective causes secondary to a bite unlikely to they could progress into a ischemic or a necrotic limb a bite from a dog a bite from a snake a bite from scorpions and those toxins can cause by what mechanism do they cause a non viable limb each bite would be different so in terms of a dog bite there's very many organisms within a dogs so that would be a later sort of subacute progression of an infective process and with snake bites you generally get you either get neurologic compromise or you get hematological compromise or you get ischemic vascular compromise from that's the question how do you get the vascular compromise the I don't know the exact I don't know the path of physiology of how a snake bite causes direct ischemia say for instance I have a cytotoxic snake how is that cytotoxic snake venom going to cause vascular occlusion or vascular flow occlusion at least in a necrotic limb through what mechanism through what syndrome it may not definitely be the sole mechanism but there is definitely micro thrombi and it's sort of a disseminated vascular inter vascular coagulation localised coagulation or micro thrombi that contribute to the ischemia and the development of the threatened limb and over and above that inflammatory process that further compromises the blood supply what happens in that compartment due to all these changes we see swelling increased blood flow initially increase and then decrease return of that blood flow what do we call that increase in the compartment in one of the compartments compartment syndrome okay compartment syndrome moving on to the more chronic side you mentioned the sepsis what's the leading cause or what's the most common cause of sepsis in a dead limb that you've seen I can't quantify in terms of in diabetics diabetics which would be the better physiology behind diabetics leading to a non viable diabetics is a predisposes to immunocompromise by the or being in a situation of immunocompromise compromise there are certain mechanisms for that one is of course the glycosylation of the white blood cells in the bloodstream further the actual peripheral vascular disease that happens with diabetes that atherosclerosis that they predispose to so if you have somebody at risk for infection and you have a decreased decreased blood supply to those areas and you have minimal trauma that combination can predispose to a infection that is inadequately controlled and progresses you see a patient with diabetic foot sepsis and you have to decide between consulative management and immediate ablation what thoughts lead you in that decision to make that decision between these two modalities of surgical management very good history also including social circumstances but if you need to be more aggressive you need to despite social circumstances a good history as to how long it's been other comorbidities that are associated with that and then obviously a very good examination with regard to having a look at the skin having a look at the pulses having a look at the atrophy having a look at the... give me an example of each of these that you mentioned how does that guide you between the two modalities ablation or consulative management I think more suggestive than history would obviously be your clinical examination so if I can lead more to that so the actual wound itself if there is gas in the wound if it's very very purulent if it is ascending and very erythematis if it's completely gangren as black then that would be more suggestive of more aggressive ablation to a level and also in a systemic point of view of course if somebody is more septic and the focus is that lesion then I would be more aggressive to try and achieve source control then obviously the actual use of their limb are really often you see they may be it's been long standing their limbs are contracted and fairly useless that would be more suggestive of if somebody has a completely contracted knee and distal ischemia would suggest more aggressive I can suggest you the patient rather than the diabetic foot set that says external trauma any form of external trauma what are the thoughts that might lead you to decide between ablation as far as the external trauma is concerned versus reconstruction and consulative management what would be the factors that would influence you to decide to rather amputate the limb from external trauma rather than to try and save the limb if I look at the limb the soft tissue the bone and the nerve involved in that limb the soft tissue is very very important to supply the nerve and the limb the nerve and the bone with adequate nutrition and support so if you have completely devitonised limb or soft tissue that is very very contaminated and torn sort of a mangled limb that would be more suggestive of ablation very comminuted fractures in multiple places that's not amenable to x fixing then that would be more suggestive of a more aggressive surgery and of course with nerve if you have transactions complete transactions and drop foot and those sorts of things that would also be very unlikely to recover and that would be more suggestive of aggressive surgery and blood supply if you have it depends on obviously how long but if you had a traumatic aneurysm and that has been missed and the leg has come back dead then of course that would need more aggressive surgery okay thank you my colleague will ask you a few short questions you mentioned the compartment syndrome earlier how would you go about diagnosing a compartment syndrome in context just to give you a sort of clinical suspicion and then of course on a clinical examination commonly referred to the 5, 6 there are many p's involved but palo pulsusness parasthesia as well as paralysis polythermia or coolness to the limb and there has been referenced in purple but I guess that's also in the same the same context but that would be very suggestive compartment pressures compartment syndrome is when you have increased pressures within a confined space where your fascial confined within a limb and that pressure is often referred to as 25 to 30 millimeters of mercury and then you have that sort of syndrome of those 5 p's that's a context of in history of trauma or a bite or something that would be in your own compartment syndrome in a patient with a low limb compartment syndrome how would you go ahead and manage the problem if somebody has the concern is is ischemia so you would need to relieve those pressures in order to salvage to salvage the limb and reap the fuse obviously being very wary of reap the fuse and not going to try and salvage a limb and sacrifice the patient at the same time but you would need to do fasciotomies if they clinically indicated and with a fasciotomy of a lower limb we would do two incisions one on the medial aspect just posterior to your in one of the lateral aspect and that would give you access to all four compartments within the leg in order to decompress the fasciaal confines and re-institutes adequate perfusion you mentioned reperfusion syndrome what do you understand under so reperfusion is a scenario where you have had ischemia and the tissues have been compromised ischemia by virtue withheld of blood so they haven't had adequate blood supply for a period of time en because of that you have the poor functioning of the cells on a cellular level you have poor functioning of the cells a lot of electrolyte abnormalities are being then re-instituted blood and those electrolyte abnormalities can reperfuse particularly calcium potassium acetic acidosis patients had risk for that on a systemic level because of the by-products of anaerobic metabolism at a local limb level is there anything that you can do to prevent or minimise the effect of some reperfusion syndrome I think be very wary of it in these sort of contexts before so always try and prevent it and always think ahead if you're going to have that sort of scenario always keep your patients well hydrated there is is growing literature towards antioxidant treatment and to have that bury that in mind high dose vitamin C is one mannitol is another and has been referred to the efficacy of that is full debate but it is a method that is used at a good hydration and of course monitoring of these electronics in that context and aggressive replacements or even dialysis if need be so I'm going to ask you a few questions my colleague will then take over and it's going to pertain of course to vascular surgery a patient presents to you with two casual tear referred to you with acute lump pain cannot absolutely stand that pain the patient has never had it before has never compared with claudication and giving you a clue obviously that this is about vascular surgery what is your work up of this patient what are your thought processes as two possible causes and your eventual management right from the description of the patient sounds like this is a patient who is suffering from something called ischemic pain and ischemic pain is pain we defined as pain derived from vascular compromise of a limb particularly the tissues of that limb including the muscles, the nerves and relevant connective tissue this patient like we've already stabbed is suffering from some sort of vascular insult and when we talk about vascular insults we talk about thrombotic events we talk about embolic events to me it sounds as if this patient is lying on more along the embolic root which involves and that's given away by the fact that there's no claudication history of what's ever so this is an acute new onset event which is sort of typical of embolic events just in terms of the embolic event embolisis in this case would be described as a foreign sort of material that is included a blood vessel and is now compromising the circulation of the tissues as we said before which is resulting in the patient's ischemic pain in terms of the work up of this patient trying to establish what is the cause of this embolis and where that embolis has come from you would first obviously establish whether the patient is stable following your ABCs of ATLS principles make sure everything is fine this patient does need any form of resuscitation a particular concern is the fact that one of the major originating areas of embolic events is atrial fibrillation so obviously you want to make the patient's cardiovascular stable in particular but that's just focusing on the ABCs we'll get back to that now you would obviously now establish that the patient is stable and once they are stable you can determine that this patient is now eligible for investigations so investigations that I would sorry I'm jumping the gun a little bit we want to start with the history taking again you want to establish onset of pain particularly maximum pain in terms of establishing ischemic time the golden sort of time period that you're looking for is under 6 hours and that's in terms of revascularizing with intent of having viable tissue afterwards you would also want to know if the patient had any previous surgeries where the patient's got any comorbid medical disease that may contribute to vascular pathology includes diabetes, hypertension any sort of other vascular events that the patient has had in terms of the patient's history itself you would talk about provocation is just to establish where there's any underlying vascular pathology and that's important not only just in terms of establishing the cause but you would also establish what kind of treatment this patient would get obviously trying to treat a patient that's really got to compromise in terms of vascular pathology would be a little bit more difficult than an acute onset with healthy arteries let's suggest that this patient has had as a no-cordication and that you clearly suspect an embolic event in a patient with clinical examinations found you want to have atrial fibrillation and what would be the clinical findings in a patient with acute embolic event with no underlying atherosclerosis the acute embolic event again going into history would be the acute onset of sudden pain moving on to the clinical examination depending on what level that embolus was now sitting typically with embola thrown up from atrial fibrillation you would expect I would want to say for glove and stocking kind of a distribution of the ischemia you would probably find that the toes are now becoming ischemic in terms of the time those toes may be gangrenous early signs of that ischemia would include parasthesia swelling of the extremity pain out of proportion you may start seeing skin discoloration you may have pulsuses limbs but that would come quite significantly later and that's in terms of the now clinical examination you know it suggests that that's a showering of smaller emboli how would that differ from a patient who shoots off a sizable embolus that say for instance includes the bifurcation of the common femoral artery now we're talking about a ischemic event of a much larger tissue surface area which comes with a whole myriad of problems particularly now like I said before you would look for signs of ischemic compromise and that would be pain out of keeping pulsus limb parasthesia swelling of that limb obviously now with the ischemic events going on blood flow is not circulating to the cells particularly the muscles and the nerves and the bone of that tissue each of them have their own preference in terms of ischemic times but with the lack of blood flow you have a lack of oxygen nutrition that leads to destruction of sort of cell membrane action potential pumps cells now start swelling and start activating calcium mediated sort of just looking at the limb what does it look like compared to the other one it will be swollen it will be pale it may have pale in the early stages may be discoloured later on palpation the limb will usually be quite tender as opposed to the other one it might be swollen compared to the other one that is obviously with the cell destruction that is going on and obviously decreased pulsus or absent pulsus distally as far as temperatures concerned the ischemic will obviously be a lot colder it will be a lot colder okay you mentioned warm ischemic time so certainly you don't have ample time to play with are there any special investigations that you would consider in this patient special investigations look again time is something that you need to not play with special investigations to investigate sort of vascular pathology this is now not looking at the origin of this in terms of looking and establishing the level of the ischemia you could consider a angiogram doplers sorry before that you could consider doplers flow doplers you could look at certain ultrasound investigations but I think that would be quite hard to establish to arterial insufficiencies but I would think that the gold standard would be an angiogram to establish exactly where it is okay the patient has a white a white kidney threatened limb right with no history a preceding history suggest of peripheral vascular disease is the arteriogram a waste of time because time is of the essence or is there something that you can learn from that from that formal dsa of ct angiogram look ct angiogram would give you a sort of cut off level could you learn that from clinical examination you would know with the establishment of the embolus is now sitting but in terms of the exact size and propagation of that embolus in other words it may be difficult to treat a long kind of segment of embolus where as a shorter segment might be how is the angiogram going to show you that it probably wouldn't actually because it would have a cut off so it wouldn't show you the distal segment so probably not I would think you might establish it in more chronic diseases collateral but that's about as well just talking in broad terms about the surgical management of this patient what are the principles involved in an embolectin at the level of the bifucation of the common femo the principles involved in an embolectin is obviously to surgical principles you are performing the embolectin we won't elaborate on the pre-op preparation of the patient we will try to show the procedure itself what you need to do is to have adequate exposure the vessel involved in what you tend to in surgical catheter in this case I would think that sure if it's something at the bifucation of common iliac surgical principles I am exposing the artery you would have adequate exposure to the artery you would want proximal and distal control you would want to enter the vessel in a sterile and safe manner you would advance your guide wire through the okay so I've got proximal, I've got good exposure I've got proximal distal control what is the proximal control of what vessel at the bifucation or would you know the common iliac or would it be the artery it would be the distal auto I suppose you are exposing the vessel in the groin for an embolectin where is your proximal control proximal control would be more towards the sterile what artery do you sling the common iliac the common iliac why would you want to go that high sorry I thought we said that the embolist was sitting at the common femoral sorry the common femoral right so you would go to the the internal external iliac vessel what is the distinction between the external iliac and the common femoral where is the name change sorry it is at the level of the inguinal iliac see would it cut through the inguinal iliac no you don't so the proximal control is up there of the proximal femoral artery the common femoral before you make your incision would be more distal I wouldn't go down as far as the property artery would sort of mid common femoral or femoral vessel distal to the to the origin of the what are the two vessels distal to the bifurcation distal to the bifurcation or the common femoral is your perfundus and then your femoral artery itself better known as the something femoral artery your perfundus femoral artery and don't superficial femoral artery so you need control over all three of those vessels unless you can make your incision the blood is going to the blood is going to squirt up to the roof is there something that you should administer to the patient before you occlude those arteries before your incision the patient so you make your incision now what? you would remove the cut of blood that is clearly visible obviously your intention is to be on the distal end of the clot you would now advance your your guard wire sorry the principle will be using a foggy de catheter I don't think there is a guard wire in both but you would advance your foggy de catheter through the clot you obviously wouldn't be doing this under fluoroscopy and the intention would be to advance it up until the point that you were getting fresh arterial blood through the I'm so crushing it the principle behind it would be to advance the foggy de catheter through the clot inflate it and retract the clot out and remove it that way the exact details is where the the guard wire is involved so you get clot out how do you know that your procedure is now adequate you would have good flow from the vessel so would you just remove the clot to go down both vessels or just one you would probably go down both vessels okay so you close up the artery now how do you release your clams you've got control over all these three vessels now you would release your distal clamp first and then you would release your proximal why the distal first before you tell your last week sorry I retract that statement I would release the proximal clamp first assess whether you have got any active bleeding from your repair and then if that is I think enough my colleague is going to ask you a few questions before I correct your numerous technical mistakes okay were this patient perioperatively what sort of complications in broad turns what sort of complications did you consider any time we discussed complications involving any procedure we want to talk about early we've obviously discussed the interoperative complication we will not talk about the early perioperative complications and then the late perioperative complications early perioperative complications would include further bleeding from the sut damage to vessels vessels and arteries that would have been sustained that are now becoming evident after the procedure if there is a closed bleed there would be a hematoma formation also possibly AV malformation depending on what are your two genetic injuries were caused by the thing the hematoma itself could cause pressure compromise of the area including nerves and arteries and veins you could get an infection in the site which would obviously form more under your intermediate to late complications and then obviously any time you're involving the vascular system you must worry about thromboemolism that could form from the procedure itself we'll be on to late complications I'm bored of that please so the thromboemolism that would form we said we're going to anticoagulate our patients when about in this whole time do you anticoagulate in terms of the exact sort of time frame in terms of number of days prior to procedure is not something I'm 100% familiar with but I would think if you're going to now do a procedure I think at least 6 hours prior to procedure you would need to start but this is an emergency procedure well then you would need to if it's an emergency you would have to pretty much give it just prior to operation and then interoperatively and then continue that on do you have any idea on how to give the anticoagulation in this instance in terms of depending on which form of anticoagulation you choose to use with this low I would preferably use low molecular weight heparin and that's because it's been shown to have as much benefit as unfractionated heparin but far fewer complications and obviously you don't have to monitor the low molecular weight heparin as much as you do the confractionated heparin I think in this instance correct me if I'm wrong we're using infusion of unfractionated heparin to be able to monitor perioperative and also as a therapeutic not only I think in the context that you speaking of is from prophylaxis so we using as treatment doses of infractionated heparin infusion okay alright so welcome to the oral examination I'm going to ask you whether you've seen patients with necrotic unsalvigable dead legs before plenty I'm sure what are the causes of necrotic unsalvigable dead limbs that run through your mind when you see a patient what are all the possibilities as far as causes are concerned acute acute limbischemia can be chronic limbischemia with an acute onset and it can be a chronic on itself so in the acute setting it could be trauma it could be a dysloge thrombus thromboembolic disease it could be intimal injury that has so an embolic source can come from the heart patients with atrial fibrillation it could be an intimal injury which has caused thrombosis and then an emboli which has gone distally and caused an acute limb acute on chronic could be a patient who has already a chronic atherosclerotic disease which has now and has an acute hit on that which could also be trauma all those things that I've mentioned already in such patients you get atherosclerosis which can lead through a thrombus formation in itself and that can also include acutely and then there's the chronic the chronic limbs which take a natural progression of which one of third get better one of third remain the same and one third get worse and that could be with patients with risk factors of diabetes smoking, hypertension and hypercholestering so those are innately arterial causes of a dead limb are they non arterial causes of a dead limb in essence every one of them has to end up being no blood flow but you've mentioned sort of interluminal causes are they other causes as far as all these dead limbs that you've seen before it can be or should I say you've mentioned all the large vessel causes are there other causes of non viable legs they can be compartment syndrome which can be caused by different reasons one of them could be trauma then they could be a simple pop causing external compression could be other causes of compartment syndrome what about toxic causes it could be from a snake bite which causes like crosses it could be from I think those would be ones that we've all seen before you mentioned diabetes in these chronic patients what is the pathophysiology of diabetics leading to non viable limbs why did diabetics develop non viable limbs it's the pathogenesis it causes diabetes causes injury to the micro vasculature and it also predisposes to hypercholesteringia which increases the atherosclerotic disease so there is micro vascular damage which then leads to propagation of fibroblast which then leads to fibrin deposition which then leads to cholesterol deposition and a thrombus now you see a patient with diabetic limb diabetic sepsis the mechanism that you've mentioned infected how do you decide what guides in your decision to decide whether to amputate this leg to the enablation or to manage diabetic sepsis conservative what are factors that you would consider making this decision okay I want to first assess if the limb is viable or not and you want to go through and then you want to see if there is wet gangrene or not which could in a patient who has in a patient who has hyper glycemia would predispose more infection so you want to assess if the limb is viable itself how would you go about that how would you make that decision okay if a patient is spreading sepsis with a patient who has a leg which is obviously not viable or a foot or a toe that's not viable how do you assess that how do you know it's not viable well there's three classifications I'm just talking diabetic foot diabetic foot with sepsis what are the other things that help you to decide whether this patient needs to go straight to theater and have the leg amputated or you can treat it conservative with antibiotics and blessings okay you want to which patient or sketched to me the patient that needs to go directly to theater and have an ablation okay I look at the x-ray there's gas in the soft tissue he needs an ablation if there is if there's obviously a black toe distilled that needs ablation if there's a patient who has are there any systemic symptoms in size a patient who has sepsis a patient with an obvious like tachycardia with raised white blood cells with a high or low temperature normal to subnormal an increased respiratory rate because the signs of systemic sepsis okay I want to move you from the diabetic that you have to decide to amputate or not maybe to the external trauma patient patient with external trauma what factors would influence you to not try and salvage the slim by various procedures rather than to amputate a lower limb what findings in a acute trauma will lead you to amputate a limb okay there's all that option of a mangled limb reconstruction versus all this early early amputation you amputate early the patient heals better goes home whereas you do many procedures and they fail so there's the mangled limb score whereas in an acute setting obviously the foot is dead the foot is dead it's a Rutherford 3 and it's unsolvageable you'd want to do an early amputation but the other things that would influence you is you look at how many structures that are damaged that's the soft tissue, the bone the nerves the blood vessels the blood vessels which include the artery and the vein so there's no point of saving a foot that has an obvious peronial nerve injury that's going to cause a foot drop so you look at the mangled limb score and assess from there on us in the way that come up with this influences you or other injuries well yes if a patient is you want to do damage control surgery also so if a patient is on a massive transfusion is hypothermic is oozing so you want to do damage control as well life of a limb ok thank you my colleague will ask you a few short questions I think the the basket questions have been covered quite well in Dr. Crawford's in terms of complications one could expect post amputation of a limb let's talk about a diabetic limb now going back to the diabetes you've now amputated dysplation so it's a baloney amputation what also the the perioperative complications one would expect with the amputated limb so the perioperative meaning intra-op we'll go past the intra-operative complications straight to the procedure ok so you get the immediate the early and the late so in the sorry it's a diabetic amputated baloney amputation for a diabetic person so it is the immediate the early and the late the immediate would be of course you want to control the hyperglycemia you want to control the bleeding you want to make sure hyperglycemia bleeding you want to decrease the perioperative time we're talking about complications now in the post-operative period I'm talking now in terms of you and now you've operated this patient what are some of the complications one might expect and what one might pre-empt and actively maybe sort of intervene in discuss those complications you're doing fine in terms of the early and late complications but focus particularly on now on early and late complications and how would you manage dysplation in one of the things you would look for how would you how was any medications that you would add to the patient's treatment that would now help the patient okay so number one there would be there would be the bleeding which you want to make sure you want to get you want to assess on the dressing changes you want to look at the infection so you want to make sure the hyperglycemia is well controlled the patient is on adequate antibiotics you want to also make sure that the wound doesn't break down so these you know assuming you had good technique in drop and the wound wasn't under tension and all then you want to manage this chronic illnesses as well because that can lead to hyperperfusion of the affected limb like adequate blood pressure control and all and then the the late complications would then be for the stump breakdown would be reinfection particularly in terms of the vascular sort of trend you know I have a diabetic patient also be hypertensive who has now had an amputation what are some of the factors that would influence your decision to treat this patient procedure or medication now the patient now is a mobile in the world she used to be able to walk around she cannot walk around anymore what would you would you consider any sort of prophylaxis against something in particular okay what I'm trying to say would you put this patient on dbt prophylaxis now and the patients haven't been offered yes of course yes is any particular dbt prophylaxis you would prefer in this patient and if so why well I would I prefer klexin over hyperin because of the it's easy to administer it gets gets better it's well controlled the hyperin is a bit tricky in terms of it's you have to do a lot of it's difficult to administer just because of the doses itself I put him on a prophylaxis dose which is half half milligram per kilogram we're not particularly we're more concerned with the principles here not so much the dosing right so you'd put this patient on dbt prophylaxis you would choose an fracturing approach you would think is a wild choice let's go back to sort of assessing this a little now you've decided to do an amputation on this patient say the sepsis is is somewhere sort of mid cough area what are those sort of influencing factors that you would look at in terms of the level of amputation you would do in this patient okay so I want to see at what level at what level the sepsis is and then how would you be guided by that what are you looking for in terms of that in terms of well you want to look at the things that are causing inflammation in that area so basically that would be redness that would be how far the foot is warm just the swelling of the foot or that part of the leg so you want to go just proximal to that especially in a patient who you know can tolerate a surgery later on you want to just you want to do a guillotine and then come back to later formalize to make sure the sepsis is under control in terms of baloney amputation obviously there's a certain point at which you're cutting a bit too high do you know what that level is now soliciting it and why we sort of look at that level and why it's important sorry you said that again you've just said we'll go to the level of air thema the sounds of infection but now in terms of baloney amputation so if it's up to mid calf level I want to see if I can well this is what I would do personally I want to see if I can get it at an area where I can do a guillotine and still preserve a bit of a flap that can later be formalized as a BKA but in a case where I feel like I can't leave a flap enough it's better to do a trunie and then later formalize it as an above me amputation


Hey y'all, Dustin Schaper here, the Keto Pro. We're going to talk about women in ketones and ketosis. One of the things, I get a lot of questions, the majority of our audience is a female-based audience. So, one of the questions I just got was about hormones, about different times of the month, about different cycles of their hormone cycles in their life, and what happens if you stop ketones? So, first off, let's talk about what happens when you stop ketones.  And the majority of the time they were in ketosis, but every once in a while they would cycle in and out. And so, ketones elevate the ability to provide energy to our brain, our muscle system, more efficiently than glucose does. Now, glucose is still very important, but high consumption of that isn't that great for us, right? So, when you stop ketones, your body won't perform as well as if you have ketones available. So, if you stop, you're going to see less production of overall energy, focus, mental clarity, mind power, so you're not going to perform as well. And if you're concerned about that, then you have to find a way to sustain elevated ketone levels. A, either do a really strict diet for the rest of your life, master fasting, and do a diet, a variation, or drink ketones. And that's why I suggest drinking ketones because it allows flexibility, allows it more excitement. It's actually easier, even somebody that does a keto diet. I still drink them because I like more because it gives me more long-term benefits and cognition. So, if you stop, expect your body not to feel as good, as great as it does with, because it's a sustainable energy source. Your body's probably not producing its own ketones effectively if you're not doing a perfect diet. So, what about hormones? So, women go through different cycles, men do too by the way, just differently. But women go through different cycles, and what happens during those cycles? And your body's going through lots of shifts and changes. And the question was as well, your body acts differently during those times. Yes, true. Actually, pregnant women go into ketones is easier. Why? Because it needs to protect the baby, right? So, your body can produce ketones very easily. At least some studies have suggested that. So, ketones are vital for that. If you want to optimize energy and focus and mental clarity and mood, you're going to feel that when you elevate ketone levels. So, does it have an impact on hormones? There's evidence that suggests it does. I have a doctor that talks about that, and you can get a video that talks about it with Dr. Andy, and talks about the correlation to hormones in itself. But let's look at it this way. During your cycle, or during metapausal symptoms, or things like that, how's your energy? How's your mood? How's your focus? How are you feeling? How's your cravings? Are they heightened? If they are, and ketones can help bring them back to maybe more of a balanced state, do you think that'd be a positive for you? Well, we're finding that it's the case. My wife has found that that helps her a lot. And so this is just a great opportunity for us to be able to do that and help her through those situations, and hopefully help her protect her from maybe over-bingiating or stress-eating and help her feel good as a mom with three kids at home that she can be more present and focused and not maybe have her moods off a little bit. And there's one more question. Actually, I think I got them all. Oh, is there studies for this? Studies are continuous. They're ongoing. And so I don't keep up with all the studies. It's probably impossible to do that. There's so many coming now. But the studying around ketosis has been around for 100 years. Nothing about it is new. The diet's been implemented for a long time. They've been studying ketone supplementation now quite a bit. And our product has a lot of ongoing studies around that. What we can tell you is the stories and testimonials just keep rolling in of people feeling better, living better, energy, focus, mood, sleep, fat loss. The things that you would need when your body goes under certain levels of stress and the proof is in the pudding. After five and a half years and going on for a much longer, people are living better and making better nutritional choices. So good on them. No matter what you're challenging or going through, you can make better choices. That's a big plus.  So I hope that helped. Ladies, drink your ketones. I promise you I haven't seen anything like this ever before in my 20-plus year career. And I wish I would have had this 20 years ago because I could help a lot more people out faster. So cheers, y'all.


Welcome to Toffy TV, here is the Everton News daily. Michael Silver has revealed why Tom Davis wasn't in the squad last night and he said it was a tactical reason to leave Tom out. A lot of people, including myself, expect that Tom Davis to start the game last night. But Michael Silver revealed that it was a tactical decision to leave him out of the squad, which is obviously four debitons starting the game. But it does make you wonder where that leaves Tom Davis in the Pekanode this season. We've seen very little of him on the pitch, where a lot of fans would have expected to see a lot more of him. He signed a five-year contract as well, which shows, or certainly we thought showed, where the player was going and what the management thought of the player. To leave him out of a cup game where you would be expecting a player to be getting minutes is very damning. Now, I don't know where this leaves Tom Davis. For all we know, Tom Davis might be involved from the start on Sunday against Wolves, but I don't know. I don't know. I suppose for Tom Davis he's just got to get his head down, keep working hard. But the manager clearly doesn't see him as a first team at this moment. When, interestingly, this time last year, Tom Davis was captain in the side and starting games in the Premier League until the emergence of Andre Gomez. So, Andre Gomez, of course, was a sub last night as well. But we've got a lot of midfielders of a certain type. Tom strikes me as a player who's slightly different than some of those players. OK, he might be as good as some of those players, but he strikes me as some of the difference. And you just wonder whether the purchase of a Wolby could be the sign that Tom Davis could be really struggling for first team football this season in Evans. So, interesting, we'll see how it goes. A lot of games left to play, things can change very, very quickly, as we've already seen. But it must have been very, very disappointing for Tom last night. But it shows that the manager's got a ruthless streak and he's prepared to take measures and where people question the manager on certain things. You know, which he can be questioned at. You know, he is a ruthless manager and if plays an apple in the way whether it's in training or when they get opportunities, they'll be left out the squad. Especially as the squad attempts to get bigger and better going forward. So, a disappointing news for Tom Davis there. Another young midfielder has left Evans Football Club today. Callum Connelly has gone on loan to Lincoln City who we played last night. Don't know whether the deal was done last night, but he's gone on loan for the rest of the season. And he's seen, you know, I think that's pretty much the end of his career at Evans Football Club. He's been at Evans for a long time and never really made his mark on the first team. So another opportunity for him to get experience, but I think he'll be taking that experience and using it somewhere else. Long term, I don't really see him as an Everton player. So, but good chance for him to go away, play for the decent side. He looked like he were decent side last night. And yeah, get game time. Obviously following the win last night, we got the draw. I never know, obviously play Sheffield Wednesday, which is an interesting tie because Dave started the season quite well after the departure of Steve Bruce. Where we'll find in around the month of time, we'll have to wait and see. But a good tie, good away draw, not too far away to travel. And it should be a good game of football. And obviously we have avoided another Premier League club. And it would have been nice to get a home draw, but it wasn't to be. Yeah, I mean, there's not really much going on today. The manager's press conference for the Walls game is tomorrow, I believe. So we'll have more on all the news surrounding that, whether there's any more injuries or Tom Davis or et cetera. Also, the possibilities of any other young players going out on loan. I believe Benny Benningamy was supposed to be leaving on loan, but that hasn't quite materialised. I'm going to have to see if there's anything in him leaving the club or any of the other young players. Even Kevin Morales, there's pictures today of Kevin Morales in an airport. So has he made a trip somewhere to make a move? We'll have to wait and see. The transfer window shuts early next week. So I'm sure the manager will have more news on that. The manager, obviously, sent all the players over to the fans last night to give them the share as well, which was a really, really nice touch from the manager as well, for all the people who travelled there. So there you go. This has been the Everton News Daily. Thank you for watching. Make sure to check out the final word when I get it edited and I get it out. If you're on Patreon, make sure to check out the footy show, the Walls preview, and that comes out as well. And just all the other stuff we've got going on. The podcast as well, which is out this week as well, me and Andy De Peve sit down for a chat about bars in Star Warsland, the jam you get. Thanks for watching. I'll see you later.