Communication ‘Acute Abdomen call for ICU bed post-op a. Prep station given, about 6 pages of notes, summarise and consolidate your points, examiner asked a lot of questions. pt w chronic history of COPD on steriods/relievers, seen in ED for being “under the weather”, unremarkable until she ate some food and suddenly had acute abdomen. objectives were to ask ICU reg for pre-op advice and request for ICU bed. b. remember to write down his advice because he will make you repeat them at the end. c. what made you think of perf viscous? PE showed signs of peritonism, Hb dropped 2 units, US free fluids in abdomen, (CXR was clear but i said i would re-do to look for free air) 4d. what fluid resus would you do? crystalloids, rapid flush. colloids if poor improvement seen, cross match pt for blood in view of rapid Hb drop €, asked me to suggest pre-op things to do. 1, ECG: look for arrythmias, T2MI, noted mild hypok so also looking for ECG signs(started quoting them but stopped by examiner) ii, repeat CXR: which i earlier said i'll repeat to look for free air il, check if pt took steroid inhalers today, told him if on maintenance steroids no need for iv hydrocort but will monitor closely iv. commented on vitals monitoring, told him i'll keep S02 threshold lower in view of chronic COPD. he asked how much oxygen to give and how ECF K* and ECG + Hypokalemia + Hyperkalemia saat Toe v. contact anesthestist f. criteria for ICU admission i, 2 organ systems impaired with acute reversible causes ii. impaired respiratory system requiring mechanical ventilation il, 1:1 nurse patient ratio iv. 1 organ system chronically impaired with a possible 2nd system being affected/impaired Communication. Parental Consent a. Son with splenic rupture, father approved op. Mother appears later crying, demands to speak to MOee ee re ene = SEN Se nen ee con een ee nee ee: b. Issues discussed i. explained indication for splenectomy ii. explained post-splenectomy expected complications and need for vaccination/abx ii, explained consent and urgency for op iv. “is my husband drunk?" focused on explaining why he was able to give consent (can receive info, can process info, able to make informed decision and communicate it back to us), did not touch on him being drunk at all v. she will keep asking you to make sure son does not speak to ex-husband, focus on medical, we do not have jurisdiction on who sees who unless mandated by law (eg. who has actual custody which is not our daiji) vi. ask her to leave her handphone number with the nurses so that she can be contacted when her son is out of OT make sure to calm her down, by being composed. explain the need for surgery, what is the function of the spleen, why we couldn't wait. why consent the father (joint custody) and had capacity ( explained what that means), is the consultant an expert in this surgery ( how would I know?! explained to her that this is considered the most common abdominal solid injury and he will be in good hands. explained to her the procedure and possible partial or complete splenectomy depending on intra-op findings. explained to her OPSI and need to be careful including bracelet. she asked about antibiotics for the rest of his life?.. explained to her the need to bring a social worker on the case to make sure that the kid is in safe environment and our priority is the kid how long will he be staying in the hospital. tell me more about the social worker? do you have to? when can | see him. ‘AOR splenic hematoma (repeat) =ICE - Patient understand dx - Follow up management: memo, call wife and employer. Young pt who was in an RTA and suffered a large splenic hematoma. Observed for 48h, remained well, but planned by consultant for further observation KIV splenectomy if hematoma ruptures. Pt wants to AOR discharge because he has an important interview the next day. Also facing financial difficulties because of wife’s new diagnosis of cancer. - Explored ICE with pt - Offered alternatives of home leave, but cannot: interview in next town - Offered writing a memo or calling employer, but cannot: weekend currently, employer unforgiving in previous cases - Offered speaking to wife, but pt declined - In the end agreed to let pt discharge, but with a memo to seek medical treatment as soon as he reaches back home - Also got pt to agree to have someone accompany him on the journey back - Given abdo advice to watch for signs and symptoms of hematoma rupture = Asked pt to sign indemnity form‘AOR, Pt daughter and patient wants to AOR. Post SMAC POD2 with axillary swelling, drain 400ml. Only preop bloods. ~ Speak to on call consultant. Inform of condition and decision to AOR. = What would you give patient on discharge if AOR. - Plan to end off: - Check through vitals chart and bloods, do bloods today if not done (only preop bloods provided) - Speak to patient first, check competency and let her decide - Speak to daughter again 1, no wheezing / coughing / fever / phlegm 2. no PND / no decreased ET 3, Smoker 4, No Pmx, other than gallstones 5, Tests at GP for SOB told to be normal 6, ICE: widowed with 2 kids, financial worries ii. Differentials: Anxiety / Panic / Respi / CVS / Anaemia / Thyroid/ Hyperventilation il, Investigations - FBC, TFT, CXR, Pulmonary function test iv, Management: reassurance Phone consultant for acute limb ischaemia i. Lady admitted for recently for mild diverticulitis, admission paras irregular HR, symptoms improving with IV abx and IV fluids. Now complaining of acute right lower limb pain. O/E Left LL pallor, pulselessness, pain not responding to paracetamol ii. Bloods: Hypokalemia (GI losses, lV fluids), Metabolic Acidosis on ABG (ischaemia) ili, ECG - premature ventricular complexes, AF tachy iv. Pick up the phone and speak to the consultant. Explain in SBAR format. 1.[s it urgent? Can we send her tomorrow morning instead? 2. Do you need a cardiologist to review for PVC before transfer? 3. What if the cardiologist can’t come down? 4, What do you think of her presumed diagnosis of diverticulitis now that she has this acute limb ischaemia? - Possibility of ischaemic bowel in view of limb isachemia and irregular heart rate 5, Do you need to scan the abdomen first then? - Said we will scan the abdomen after the transfer. 6. He asked me if it could be mesenteric ischemia straight away ~ | said the abdomen so far has been soft non tender > continue to do serial abdo exams KIV scan if likely 7. Ok you can send the patient over. LLischaemia - 22 year old medical student, cyclist hit and run by car, LOC 15 mins until ambulance arrived, GCS 15, haemodynamically stable. Has open fracture of left tibia/fibula with nil cold leg, also has u/s abdo with free fluid, but GS reg has examined and abdo is SNT~ They had a cordless phone in the room, trauma consultant on the other end, basically ISBAR, ~The trauma con asked a lot of questions, some questions purposely regarding information that was not provided (eg, whether patient has a c-collar on, whether patient is dehydrated) - Then gave a plan~ for CT head/abdo/LL, Xray C-spine, if anything worsens to contact, him immediately. Initially | thought it was a test, told him that | think the scan will delay the operation as the patient has the ischemic limb which is more urgent, he got abit annoyed and asked me if | would put the patient under without clearing his head after ‘an RTA with LOC.SBAR TEMPLATE — to submit issues of concern to NNLC ‘The SBAR (Situation-Background-Assessment-Recommendation) technique provides a framework for communication between members of the health care team. Although this technique was original developed to target a patient-centered Condition, the NNLC wil implement this technique to communicate and address crtcal issues to support immediate attention and action by the committee, This SBAR tool was developed by Kaizer Permanente, ‘Siluatio ‘What isthe situation you are writing about? ‘+ Identity set, health care site, area, tile, date, etc. ‘+ Briefly state the problenvissue, what ist, when it happened or started, and how severe. EXAMPLE: Background: At the John P. Morgan Health Center, duting FY 2008, the Public Health Nursing (PHN) department ‘consisted of 5 PHNs. During this time, 3 PHNs were detailed to outpatient on average 40% of their time and supervised by the Clinical Director, which decreased the PHN Provider Productivity significant. ‘The IHS Public Health Nursing scope of Practice is designed to build healthy communities by promoting healthy behaviors and ifestyles through provision of care based on a primary prevention public health model ‘The American Nurses Association Scope of Practice Model describes the practice of the PHN as placing emphasis on primary prevention in all heath promotion & health protection strategies withthe focus on Population level outcome. ‘The GPRA objective related to the Health Promotion & Disease Prevention correlates directly with the PHN program funding & is most effective wih the PHN planning, developing, & supporting systems in the ‘community setting PHN visits are done primal in the home, PHN specialty clinics, PHN office settings, school & community sites with primary prevention as the focus for meeting the IHS mission, PHN core services are divided into direct & indirect care activities listed in the IRM document with do not ‘cover services defined in the clinic setings supervised by another dicipline, ‘The standard PHN position description, which is held at a minimum educational level of BSN, describes PHN supervision directly under the DPHN & with the scope of community focused primary prevention ‘Assessment What is your assessment ofthe situation? EXAMPLE: ‘Assessment: A lack of adherence to the defined standards identified in the PHN PD. Poor use of PHN services in addressing public health issues. Disregard for IHS line-item funded PHN postion. ‘Recommendation R ‘What is your recommendation or what do you want (say what you want done)? EXAMPLE: Recommendation: NNLC will support the following recommendations- 41) The PHN funded positions must follow PHN job description duties with education qualifications ‘adhered to & functions with primary prevention focus under the direction of the DPHN; therefore, the utilization of the PHN staff in their highest potential capability. 2) PHN funded positions will no longer be detailed for non PHN-duties. NLC reviewed on: (date) Recommendations were made on: (date) Was this forwarded to the Chief Nurs Ne. 60, on what date:Management of free fluid in abdomen Benign oesophageal stricture i. 60 year old man with history of smoking and alcohol consumption presents with dysphagia. Your consultant is gone off for a meetig and you are tasked to counsel for OGD, biopsy and dilatation under GA. Inx showed Anaemia, raised bilirubin and LET ii. apologise consultant not around, reassure that he will be kept in the loop about discussion and any doubts, can arrange for him to speak to consultant. Check what the consultant has explained to her before. Explain indications, risk (risk of GA + procedure), benefits b. If biopsy shows Ca, how to mx? il, Exalain indications, what procedure involves, procedure risks, what to look out for post procedure, TCU plans. iv. Patient asks why does he keep salivating? cos he hungry v. patient asks if his smoking and drinking has caused him to have cancer Patient kept asking if this is malignant, if his drinking and smoking caused this,| told him we cant know for sure till the biopsy, told him low risk of bleeding, infection and perforation, ete. he said how soon will we know if there is a perforation. Didn’t get the chance to even look at the examiner, very talkative patient, kept talking til the bell rang with all the candidates. Guess we all dad badly?! b. Update consultant regarding patient with oliguria, use SBAR i. Likely AKI secondary to dehydration ii, No abdomen signs at all ili, Told him would hydrate and serial abdominal exams and update again and case finished 3 days post left hemicolectomy with anastomosis with oliguria, 1 signs of SIRS on ABG and obs chart. causes of shock in this patient? do you want me to see? what do you want to do, fluid challenge him? what fluid, dose? do you want to transfer him? 2. ISBAR ~ Patient on post op day developed axillary swelling after lumpectomy and sentinel node biopsy but daughter wants to take her home so talk to the consultant on call and ask him to intervene, The dates on this were from last year, past paper question of course but | got confused with the dates. Had to make a mental map of dates spanning over a month, from last year. Not nice during the exam, wont pass this one | think because | didn’t notice the patient had longstanding COPD and LVF and consultant asked me about that in particular :S 1. Counselling of patient for hernia repair, patient on warfarin - Patient has a recurrent inguinal hernia (previously repaired 30 years ago), legally blind from cataracts, has had mechanical heart valve replacement on warfarin, anxiety not on medication. Already previously talked to consultant in clinic, but now comes to clinic as unsure about warfarin and concerned about operation the patient who had a blind walking stick and wearing sun glasses. = Went in to the room with 2 examiners who did not utter a word the entire 10 mins, andIntroduced myself, asked how | could help him. - Basically concerned regarding heart valve and warfarin - was under the impression that he had to continue it as his cardiologist had previously told him he needed to take it for life. - Explained that | would check with the consultant in charge regarding this as the usual practice is to stop warfarin for operations due to the risk of bleeding - Explained that if warfarin was stopped, the risk of thrombosis is present due to his heart valve, explained the role of clexane until the night of the operation — explained this will involve injections twice daily ~ patient said he lives alone and will not be able to manage, offered to check with the nursing manager on whether nursing services will be able to be provided, otherwise offered to admit patient until the operation Reassured patient, asked if any other concerns, whether patient knew what operation he was having and why 14, Speaking to ICU registrer for potential need of ventilator to a pat Duodenal perforation and emeregency operation was planned nt who had come in ER with a, Says no bed is available then what b. Asks certain investigations to get done and then asks to repeat what he said 15. Councelling of patient who wants to get LAMA, Had traumatic splenic laceration, being manged conservatively 16. Stem: Guy is motorbike rider. In RTA by hit and run, Was unconscious initially but GCS 15 on arrival. Admitted. Ultrasound showed ?free fluid in paracolic gutter. Xrays showed left tibial + fibula fracture ‘open fracture. Noted by nurse to suddenly have a cold limb + pulseless. Please inform trauma consultant on call. Blood investigations on admission all normal. Raised CRP and TW only - Basically SBAR and spammed him with all the information - Asked me for my plan of management. (| said CT brain, AP, send to op, start ABX = What can | do before sending to OT (he was looking for analgesia + traction) ~ What blood investigations will u send for = How will you fix his fracture (I said external fixation. He asked why) - What will you do for the wound (I didn’t really understand initially, but he wanted me to say debridement of necrotic tissue) 1, Call consultant in other hospital for transfer 1a. Your boss made a mistake did a lap chole now got CBD injury need to transfer to another hospital with a HPB surgeon for better management b. Whole list of blood investigations there must tell bout the cr (aki) as well as biliary obstruction, raised TW and CRP. c. They use a cordless phone with intercom so no one else there with u do take your time to look through the investigations and op notes Consent taking for paeds patient for lap appendectomy, a. Consent from wife but kid already in OT induction room b. Wife insist on seeing kid first but cannot go in but need to take consent c. Made worse because surgeon on call killed the husband last year in some crazy op so once wife finds out the surgeon is Mr xyz she will throw a fit and ask for another surgeon (but there is no one else) 14) Communications: Explain to angry wife of p: int about malignant ascites12. Update trauma con re: open tib/fib fracture in ED. https://www.youtube.com/watch?v=fsazEArBy2 - One prep station prior to this one - given case notes, no vitals chart - Case notes had many entries (typed out) from GS, radiologist etc. ~ Basically young guy, RTA, LOC, GCS 15 OA at ED, vitals stable - Fluid resus given, GXM done - Blood results more or less normal - Right tib/fib open #, gross soilage, antibiotics + ATT given -$/B GS, abrasions on left flank, abdo soft, does not think needs CT AP but ordered U/S - U/S- difficult exam, ?LHC free fluids, suggested CT AP - Pulses initially not mentioned, but nurses later noted foot getting colder and paler, = XRs showed tib/fib #, right hand MC tts = Next station was to call consultant regarding case. ~ Asked - why are you calling me now (will need overnight surgery], why did GS ask for U/S when they felt abdo was normal (wanted to hear about the abrasions, possible splenic injury) = Plan - NBM; C collar; reduce and splint tib/fib -> reassess pulses and neurology, KIV with bedside doppler - call vascular if necessary; update GS; CT brain, C spine, A/P; CT LL angiogram if pulses still not well felt (I didn’t offer this at first, he had to prise it out of me) - People | may need to call either pre- or intra-op - OT, anesthesia, GS, Vascular, Plastics (again, he had to drag this out of me) Prep reading 9 min. Discuss case with Trauma consultant over phone ~ 21 yo med student, car hit him while riding bicycle at 2330 hrs. LOC for unknown amt of time, but was consciouss by the time ambulance arrived (~1Smin). On arrival to A&E, haemodynamically well. O/€ Right hand swollen, abrasions left upper abdo, open fracture left leg. Abdo soft, non tender. GCS 15. Xrays ~ Right hand MC fracture, Left tib/fib fracture. CXR normal. GS registrar saw — No need for emergency laparotomy for now. Suggest US abdo. US abdo subsequently shows ?free fluid in left para-colic gutter. ‘At about 120am, left leg became pale, DP/PT pulses not palpable. Worsening pain Bloods given Hb 11. UECr, LFTs, PT/PTT normal. Tetanus and Abx given in A&E. 2L N.Saline given. GXM pending, 8 Call trauma consultant to handover case B Who do you want to get involved In this case? Plastics, ortho, GS, B Any other investigations you want to perform? ® Why you think he needs GS involvement? Why Plastics? CT scanner down, talk to patient’s wife - One prep station prior to this one - case notes given Patient referred from GP for ascites Peritoneal tap - malignant cells on cytology - Tumour markers sent, pending Planned for CT AP today, but CT broke down. Engineer sent for, coming tomorrow, Twill only be up next week, Radiologist offered to do U/S abdo today = Consultant was supposed to S/T wife, but had to go to ET.- Registrar wrote in notes that if patient very SOB, can consider therapeutic tap ~ Task was to update patient's wife ~ Angry woman ++, Must be very tiring for the actress - Aside from normal questions, wife also asked about what we can do if patient still very SOB -> therapeutic tap ~> asked how often we can do it, what the risks may be = Was also angry that reg told her all hope is lost, - Had this fixed, unshakeable idea that all cancers are curable; | tried to gently disabuse her of that notion Just stay calm folks, she ran out of steam eventually Patient came in for pre-op check up for cholecystectomy. Consultant is away and ask you to assess patient. Patient complains of difficulty breathing especially at night these few days, 2a/w tingling sensation in limbs. Also has abdo pain at times with loose stools. Hx sounds like anxiety attacks. a. Still must rule out medical causes - Fluid overload, Pneumonia, Pul embolism, Angina, Hyperthyroidism before coming to a dx of anxiety attacks b. Assess for potential causes of anxiety attacks - explore how she felt about the surgery, any areas that she is unclear of, is she afraid of the surgery, TLC a bit. Might need to offer to explain the surgery again. . What kind of investigations do you want to do? Rmb to do TFT d. How to manage this patient? POD 1 post-left hemicolectomy for sigmoid adenocarcinoma with liver biopsy for sus Intra-operatively had slipped clamp with blood loss. Now anuric, IDC already flushed. Hb slight drop, renal panel shows AKI with raised Ur and Cr. Have to speak to on-call consultant regarding low urine output. - Introduce yourself, pt’s primary consultant and pt - SBAR = What are your differential diagnoses for the pt? Is there an anastomotic leak? - How are you going to manage the pt? Does he require HDU transfer? Does he require op now? = IF HDU is full, who are you going to speak to? - Does the consultant need to come and see him now? 14, Call Vascular consultant. 66 lady with ?diverticulitis and now has one hour of acute limb ischaemia. ECG shows a fib. New dx ~mesenteric embolus, ALI. What imaging to do. What to anticoagulate with ‘and how. How to transfer (type of ambulance) L-consent OGD for esophageal stricture . 2-phone call to vascular surgeon about patient presented with acute limb ischemia ( on background of acute diverticulitis and atrial fibrillation ) pt was unstable with metabolic acidosis , asked about immediate management ? Amenable for transfer ? ‘Whats the likely cause ?( AF) Type of heparin will be used ? AORAnyway is POD 2 s/p R SMAC, patients daughter wants to AOR because she doesn’t want to travel to and fro between the hospital and her own house. Environment is not ideal because her husband and herself work as school teachers, and she stays with 2 teenage daughters. | think also got a dog. She has convinced the mother to go home, although prior to this the mother was more keen to recover in hospital before going back home. 4 pages of labs are all normal -- but note these are all preop Call your consultant to tell her about the situation. Salient points -- 58 yr old Caucasia lady who is POD 2 R sentinel lymph node biopsy, then continued to perform SMAC. No intraop complications, blood loss minimal. Postop D1 well, POD 2 developed 808, mild tachycardia HR 95 and BP holding 135/90. Drain output 410mls (bloody) <- 30mls (serous). Axilla is also puffy. Use the standard SBAR format, and update consultant as per how u would on a normal ward round. No biggie. Form to sign for AOR, offer to update the team8's primary consultant. &.quotils there any policy in the hospital that we can force her to stay in for treat ment?" Hmm. | said if she is mentally competent can sign AOR and we can't keep her unfortunately (i dunno whether this is right). Then she asked, so is the pt mentally competent? | said that i hadn8't assessed formally, but noted from the notes that it seemed that she was. Transfer of care Young motorcyclist involved in RTA, wearing full leathers and helmet at Quite a few pages of info from patients notes - documented by reg that ST1 should call for transfer to CTVS before going to see the patient - noted in patients bag an appointment card for a diabetic clinic this coming Tuesday = patient GCS 14, PR 120, HR 100/80, T 37, complaining of right sides chest pain, 4L crystalloids given so far, requested 6 units of blood for standby ~ noted left thigh swollen, no open wounds, ?fracture - no Thomas&H39; traction yet - CXR: widened mediastinum, bilat pleural effusions ~ AXR: psoas shadow not seen, dilated small bowel loops ~ Left femur XR: shaft fracture = CT not available for next 3 hours as itis being serviced = registrar also documented insertion of chest tube on the right. Swinging fluid with 200mls of blood stained fluid - Hb 8, otherwise FBC normal, UECr/LFT normal, CRP raised very minimally - pH 7.32, Pa02 10kPa, PaCO2 6.0kPa, HCO3 19 1e of injury Wanted to give SBAR but examiner kept interrupting to ask questions = what is the issue? = will you do CT scan? = what will you do for his C-spine? = what are you going to do for his leg? is there any abdominal issue? = what are you going to do about the blood pressure? - why should you not increase the BP? - prevent further bleeding - what are his blood abnormalities? = why do you say metab acidosis? - who will accompany the patient? 18. Angry patient whose operation got cancelled again (Communications) Previously arthroscopy cancelled. Symptomatic, Now here for arthroscopy again. Op cancelled due to‘emergency case. Patient frustrated, Went in preparation bay to find a stack of about 10+ pages of notes ranging from patient details to patient's GP letter to blood results. - take note of all the dates, as they may not run in order - you have 9 minutes to write down on the papers provided all the information that you will need, before going to the next station to talk to the patient The story: this guy has left knee pain, and his GP has assessed him to have possible meniscal tear. Wrote referral to Ortho. Ortho assessed him, recommended him for arthroscopy for diagnosis KIV repair. Op was scheduled last month, but got cancelled due to some reason, Also noted CRP at that time to be high, possibly related to sinusitis. Rescheduled for operation. GP wrote another letter urging Ortho to expedite operation, as his work as postman is affected, and he has been putting on weight. Also, he is in pain Knee xray shows joint space narrowing. However, this operation will have to be postponed again as, consultant has to attend to E-trauma. - ithelps to write a numbered list of the issues you need to address with the patient. 1) his knee pain he would tell you his ibuprofen has been causing him gastric pain. give him alternatives 2) weight loss - swimming, physio, etc with analgesia cover 3) work as postman - offer to write to employer to explain situation and cover with MC 4) sinusitis - must get GP to sort it out to prevent operation being cancelled a 3rd 5) offer avenue to complain - PALS Patient Advice and Liaison Service 6) offer to talk to wife 7) assure him his operation will be placed on priority list, etc ete - it helps to just keep quiet and let him talk, so that you can understand his issues that need addressing. Of course with the usual cues of listening in conversations like nodding etc talking%6to%a%patient, %whos%operation%was%postponed% twice. %This%time%surgeon%has%gone%for%e*OP.%Remember%the%MC, %analgesia, % try%6to%get%an%early%appointment%tor%see%con. Comms: Interval cholecystectomy POD2. Op uneventful, 2 clips to CBD 2 clips to cystic artery, but since yesterday worsening abdo pain with tachycardia, US shows free fluid in abdomen no CBD dilatation. Labs show TW 18 and CRP 50, bilirubin raised (something like that). Your consultant thinks there is bile leak from CBD injury, wants you to transfer to HPB consultant Prof Archibald Rose at regional centre. His reg picks up. Reg not too happy that your labs are from yesterday and nothing was done now you are calling at 4pm on a Friday. What do you think he has? Where is the source of the bile leak? Do you have any evidence where it's coming from? Could you arrange ERCP to confirm the source of the bile leak? Is it urgent? Will you need to speak to anyone? (Bed manager) 8) comms: call a consultant to discuss abt a case expected to read through 'case notes' and piece the story together within ten mins prep station. scenario was an elective left hemicolectomy for caecal tumor, with liver biopsy for suspected mets. currently postop D1, having persistent tachycardia 120 and hypotension SBP 90-100 post op, temp 37.5. postop bloods unremarkable except drop in Hb from 12 to 10, Cr 116, Urea 16. ECG normal - no MiI/PE. CXR clear. pt documented as having benign abdomen, appears dehydrated. 1/0 in negative 150mls balance, GW nurses said theres no urine output in IDC. asked to call consultant on call, as consultant incharge is on leave. - asked who the consultant of the case was (need to pick up this info in prep station, some candidates didnt realise leading to some confusion) - asked to summarize the case ~ asked &139;50 what do you think itis?' (offered dehydration, need to check whether catheter is blocked&39; - asked for plans of action, whether pt need to be brought down to H- asked whether candidate feels the consultant oncall needs to come back (said no, but will all him again if pt does not respond to fluid resuscitation or the repeat set of bloods shows any worsening. offered to proceed with CTPA if has desaturation, but will keep on clexane and TED stockings for now) - asked whether it is possibly an anastamotic leak? (i offered that as pt is non toxic, its very unlikely. but i8#39;Il do serial abdo exam, and let consultant know again if pt becomes peritonitic) 2. CSI prep Reading station Repeated question, patient POD 3 lap chole now with ? bile leak. Abdo pain with jaundice, bloods given TW CRP bil high. Fluid collection noted. The consultant was very good, all he wrote in the entry was to transfer to HPB centre. Your job is to call some superbigshot Prof about the transfer and the current management plan. For the reading stations, you are given a small stack of case notes, lab results, scan results, and you have 9 minutes to process them (which is honestly a luxury). So use this time to SBAR properly, and try to anticipate what possible qns they will ask. - differentials, management, why need to transfer and cannot manage at the current hospital etc. 3.cS1 The phone to call the Prof was in the middle of the room. | took about 1 min before figuring out how the phone worked. Just go with the normal SBAR and it was no problem. Possible dx - bile leak from damage to CBD, clip slippage, retained stone. Hardly asked me any questions at all and had lots of time left over, to well, stone. Management usual -V drip, NBM, roc/flagyl, arrange for MRCP (ERCP centre closed), PFO bloods 15. Was told to call consultant re a post op pt with low urine output. Pt had a elective low anterior resection w/ ?primary anastomosis. In the end pt was underloaded. Pt only had 800ml over 2 days and pt was NBM. Comm skills Scenario: 60 yo man post left hemicolectomy for sigmoid Ca, POD1, oliguric. Mildly raised Cr 115, I/O chart, vitals chart given. Call consultant to report the situation and formulate a plan. ~ Basically do as you would in real life, remember SBAR. | volunteered to transfer pt to HD for monitoring, KIV insert CVC. Ensure you have all the facts on hand so you don’t have to keep flipping notes to get the numbers when you call. There’s a prep station before this so you have 10min to write down all the impt facts on one sheet. 3 rd station - Communication skills, giving and receiving information. Essentially, this station is18 minutes long. You have 9 minutes to prepare in a room and another 9 minutes in a neighboring room to perform the task. Stem: This post-op day 1 patient noted to have low urine output by ward nurses. You are the MO on call seeing this patient. Please see the notes and summarize the events and come out with a management plan to update the surgeon in charge of her.Came to this room with temperature, BP, HR chart (took some time to understand as it looks different from local charts. Essentially, patient has tachycardia, low-grade temperature, mild hypotension and a narrow pulse pressure. Urine output is 10-20 mls/hr for last & hrs. Received only 1200mis of NS for POD1.) Notes documented that catheter is not blocked. Operation notes stated some blood loss but transfused 2 pints. Last Hb 12. Last TWC 14, Renal panel showed raised urea and borderline high creatinine. Results given can be quite misleading if you don’t check the dates to find out the sequence of events. Eg. they attached a pre-op renal panel (at the back of the case notes), which appeared normal, but somewhere in the case notes it was documented with the latest renal penal results (which showed the above changes mentioned). | did most of the talking by summarizing the case and giving him that my assessment is that he is dehydrated. | will want to start him with blood transfusion, which | later retracted, and say IV fluids instead. Said that | will ive 1LNS over 1 hour and continue monitoring closely in wards. | will repeat bloods tomorrow morning and if HB downward trend then to transfuse. If no response to fluid challenge overnight | will insert CVP and monitor in HD and monitor further. Consultant asked whether he needs to come down and see this patient. | told him that | will fluid challenge the patient first and then update the consultant again subsequently. ‘Actor was quite friendly but persistent in wanting to go home. | first got him to tell me what he knows about his condition. Then asked him about his reason on wanting to leave hospital so soon. His reason is that he has important job interview in 2 days time and that it will give him a significant pay rise. His wife has CA breast and he wants to earn money to bring her on holiday. He does not want to leave his wife alone at home (another town). He talked for quite long before he shagged out and then | asked him is there other reasons besides the ones he just told me? He was quite bemused and said: Is that not enough? | laughed also and said that is quite good enough. | explained that his condition is more serious then he thinks and although he is stable now, the splenic hematoma might rupture anytime. If he is outside walking about, he will not make it back to hospital in time. Told him repeatedly | understand his situation but in this situation it is more important to watch his own health first. if something happens to him, his wife will be even worse off because no one to look after her. Offered referral to inpatient liaison officer to arrange for wife to come over and stay with him in the ward or nearby hospital. Towards the end the actor interrupted and said he still wanted to go home. | told him that we cannot stop him and that there are risks involved that he must understand. | started to re-elaborate the reasons as | did not want to give in to his AOR request because the stem asked me to persuade him to stay. Saved by the bell in the end!q ils info giving /ecie ing — talk to coll Call HPB surgeon about bile leak. No info abt ur own guy. Only know that previous cholecystitis, Jaundice x 6/12 ago, no LFT, no known previous ERCP/retained stones. Routine lap chole. Notes very brief, no vital signs (dothey want met lie about it?) POD! jaundiced, labs show high bil. lightly tachcardic. U/S showed flu in peritoneal cavity. ERCP service decided to close shop cos of staff shortage. Consultant went for nonsense non-urgent meeting. POD2— documentation forthe moming rounds are the best, consultant just wrote a onecliner for the (on-call drto cal for transfer. No vitals, nothing. Called guy, wanted your candidate number over the phone which kind of broke my momentum as | was read to deliver the SBAR. Stillwent ahead with SBAR. Guy asked for causes of bile leak — mentioned allthe usual cystic stump clip slippage, CBD transection, retained stones. What to do? Transfer, ERCP delineate anatomy KIV stent vs HJ. Meanwhile drein insertion, start abx, monitoring Inform fam. ‘This is acommonly recycled past year que, the dates in the question were all ike 2 years ago so you pretend you time travelled tll 2 years ago. Thankfully | mugged all the different types and location of CBD damage and could deliver my speech. Examiner says ok, bed ready in his hospital and to transfer patient. Thanked examiner. Bell rang. [_Newrnetecive ain] 4 4 oer Ul U5Se arenes |] Povonilbopie Ce] ERCP sent nearton =m Laparoscopy, lavage, drain t Inserion* epaieak ERCP + ent 4 T common bile duct stones were identified and an endoscopic sphincterotomy performed in order to retrieve these and allow any further stone fragments to pass, An intemal biliary stent was routinely left in situ in order to promote preferential drainage of bile into the duodenum attenuating the leak and allowing it to stop. These were removed in all patients 6 weeks after discharge. ERC has both a diagnostic and therapeutic role.6 It allows identification of both the site of the leak as well as any residual stones within the bile duet that may be contributing to it, Such stones can be removed and various strategies used to reduce the pressure gradient between the bile duct and the duodenum created by contraction of the sphineter of Oddi.6,7,11 This encourages the preferential flow of bile into the duodenum thus attenuating the bile leak and allowing the site to heal nsert either nasobiliary or internal biliary duodenal stents. - Communication 2: Discharge letter to GP regarding Seroma. if | remember well there was also a reduced Hb which needed checking by GP and Seroma to be reviewd in Clinic and aspirated as needed. the plan is pretty much written in notes but just need to be efficient in summary and time is a real factor in this station8, Information giving: Jehovah's witness. Describe what we can do to minimise bloos loss. Discuss options for replacement (what won't be done, reassuring that we won't transfuse.) Telephone ~ refer a patient with a possible common bile duct injury post lap chole to the local liver unit. Questions regarding what do you think may have happened ~ clipped the CBO instead of the cystic artery, ? retained stone. What is billary perotinitis? Does this patient need transfer now? telephone conversation regarding transfer of traume patient with widened mediatinum(CXR) with CT consultant @ regional cardiothoracic centre.