CLincal scenario random thoughts Flashcards
1
Q
Splenic injury signs and symptoms
A
-LUQ tenderness
-Kehr’s sign: pain in left shoulder tip when pt is supine and legs are elevated due to blood in peritoneal cavity
-Shock
2
Q
Post splenectomy counselling
A
-I would check trust guidelines
-Counsel on signs and symptoms of sepsis from encapsulated organisms -Vaccinations once stable and within 2 weeks before discharge
Antibiotics:
–> adults: review at 2 years
–> children: until 16 and at least for 2 years
3
Q
AAST spleen guidelines
A
1:
-subcapsular haematoma <10%
-Parenchymal laceration <1cm
-Capsular tear
5:
-Shattered spleen
4
Q
Pt with cardiac history
A
-Look for recent echo/angiogram
5
Q
Older patient
A
Always ask for performance status
Collateral hx
Respect form
Consider DNACPR
Capacity
LPA
Advanced directive
6
Q
Pt with splenic injury
A
Shock index (HR/systolic bp)
–> looks for occult shock
TXA
CT AP triple phase
After:
–> counselling
–> vaccines
==> antibiotics
7
Q
Confused patient
A
TEP form
? capacity assessment
LPA
Advanced directive
8
Q
Hernia preop
A
Ensure marked
9
Q
Signs of strangulation
A
-Raised lactate
-Peritonism
-Free fluid on CT
-Hypoenhancement of the bowel
10
Q
Post op care:
A
-Remember DVT prophylaxis
11
Q
Hernia repair
A
-Mesh contraindicated if risk of contamination `
12
Q
Patients refusing blood transfusion:
A
-Which if any derivatives of primary blood component are acceptable
–> Hb, plt concentrate, coagulation factors, globulins, interferons
–> escalate to haematology
Ensure patient has capacity
Autologous transfusion
–> pre donation, cell salvage
Pregnant women can refuse transfusion if risk to unborn child
Ask + document if patient would refuse in life threatening situations
non emergency:
–> ask and document if pt would refuse in lifethreatening circumstances
13
Q
Jehovah’s witness unconscious patient
A
-Must act in best interests
-Can transfuse to save life or prevent deterioration, whilst using minimal blood possible
Unless signed and witnessed advanced decision document is available
–> relatives or associates may be invited to produce evidence
14
Q
Jehovah’s witness child
A
-16 or above: same as adult. Can consent, but if refusing life threatening transfusion can be overruled by court of protection
-In emergency, act in best interests
-Children: act in best interests, transfuse in case of emergency
15
Q
Gillick competence
A
-<16 with sufficient maturity to understand can consent to treatment. However, if refusing life threatening treatment act in best interests
16
Q
SBO guidelines
A
-ASBO guidelines suggest without signs of ischaemia that a period of 48-72 hrs conservative management is safe
17
Q
Cardiac history
A
Look for recent echo/angiogram
18
Q
History
A
Always ask about performance status
19
Q
New cancer diagnosis
A
Always see with CNS
20
Q
Antiplatelets
A
Electively:
–> Did they stop taking 5-7 days prior
–> Risk of cancelling
Emergency:
–> Could consider platelet transfusion
21
Q
Unwell patient environment
A
Ensure in resus
Ensure trauma call put out
22
Q
Senior registrar wants to have training opportunity
A
? could swap, they could do laparotomy and i could do hernia
23
Q
Bleeding patient
A
TXA
Shock index–> predictor of occult shock
CT triple phase
24
Q
Diabetic patient
A
Sliding scale
25
Hernia
Always mark the side
Consent for bowel resection/stoma
26
Comorbid patient requiring bowel resection
Explain decision making process for stoma vs anastamosis
Risk factors for poor anastamosis:
Patient factors
--> smoking
--> medication (steroids, immunosuppressants, vasopressor support)
--> diabetes
--> obesity/malnutrition (low albumin)
Surgical risk factors:
--> Emergency surgery
--> extended operating time
--> peritoneal contamination
--> oesophago-gastric/colorectal anastamosis
27
Signs of strangulation
--> elevated inflammatory markers
--> high lactate
--> peritonism
Imaging
--> free fluid
--> hypoenhancement of the bowel
28
Female patient
Pregnancy test!!!!!
29
CT needing training opportunities
-What skills could they do in this case
-What would be transferrable to on call, e.g. establishing pneumoperitoneum
-Suggest courses (core skills in laparascopic surgery)
-Escalate to educational supervisor, clinical supervisor, tpd
30
Equipment not available
--> speak to theatre staff
--> speak to staff in other theatres
--> speak to theatre manager
--> speak to adjacent hospital
--> speak to consultant or consultant in other team for alternatives
Ending:
--> discuss with procurement team/rep
31
Poor staffing escalation
General manager
32
Good buzzwords
Goal directed resuscitation
Root cause analysis after never event
Datix
Never event
Duty of candour
33
Audit cycle
Set standards
Measure current practice
Compare results and standards
Reflect plan and change
Re audit
34
Stepwise escalationq
Primary consultant
Clinical supervisor
Educational supervisor
TPD
Clinical director
35
Antibiotics not prescribed to patient
Look for systemic factors:
--> was f1 not on round
--> were they busy and unsupported
--> Have they had teaching on appropriate antibiotic prescribing
36
Training related problem
-Match log book against what is required to gather information
-Amicably sort with other trainees: can training opportunities be exchanged?
-Escalate appropriately
37
Avoidable errors:
-Duty of candour: explain, apologise to patient, letter at later stage, outcome, preventative measure
-PALS
-Datix
-Self reflection
-Audit
-Discuss at M and M
38
Consultant with complications
-Gather information
-Anonymised audit: are there other factors e.g. higher volume of patients, or more complex patients
39
Bullying
Frequent to speak up guardian
40
Patients who refuse blood transfusion
-Which if any derivatives of primary blood component are acceptable
Autologous transfusion
--> pre-donation, cell salvage
Non emergency
--> jehovah's witness hospital liaison committee
--> document capacity, ensure has understood risk
--> pregnant women can refuse treatment even if risk to unbon child
--> ask and document if pt would refuse tx in life threatening circs
41
Refusal of transfusion in unconcious patient
Must act in best interests
--> can transfuse to save life or prevent deterioration
--> unless signed and witnessed advanced decision document is available
--> Relatives or associates may be invited to produce evidence
42
Children refusing blood transfusion
-16 or above: can consent to treatment, but if refusing life threatening treatment can be overruled by court of protection
- in emergency, act in best interests
43
Gillick competence
-<16 are children. Do not consent or refuse to treatment
->Howver if sufficiently mature can consent, unless refusing life saving treatment in which case can act in best interests
44
Health LPA
Can overrule if you think not in patients best interests
45
No capacity:
Avanced directive
Consent 4
LPA: health and welfare
If acting in best insterests
--> encourage participation in consent process
--> find out patients views
46
IMCA
-Via court of protection/local authority
-Part of best interests decision like major amputation/life threatening operation OR moving to long term care facility
-No time if acute emergency
47
Unsupervised clinic
Not safe
48
Antibiotics
Trust guidelines
Microbiology
49
Closed loop communication
In closed-loop communication, the person receiving instruction or information repeats it back to make sure the message is understood correctly, and the sender confirms to “close the loop.
50
Diabetic patient
First on list
VRII
51
PR bleeding following anastmosis
Staple line bleed
Bleed from venous plexusA
52
Audit definition
Comparing practice against a standard
53
Research
Creation of new knowledge
54
QIP:
-Structured, systematic approach to enhancing processes, outcomes or efficiency within a healthcare setting
Uses plan, do, study, act
Plan: the change to be tested or implemented
Do: carry out the test or change
Study: collect data before and after the change
Act: plan the next change cycle or full implementation
55
Audit vs qip
QIP focuses on making things better
Audit determines whether things are being done correctly according to a standard
56
Difference between leadership and management
-Leaders inspire, set the vision and drive change
-managers: execute plans, maintain order, and optimise efficiency
57
Facial expression:
Smile!
58
Op note lap chole
-Was it converted to open?
-Did they do cholangiogram
-Any mention of fistula?
59
Lap chole presenting post op with jaundice
-Bile leak and collection
-Cholangitis
-CBD injury
-Bowel injury
60
How long does pneumoperitoneum last post op?
48-72 hrs
61
What is a never event?
Serious, preventable patient safety incident that should never happen if proper protocols and safety measures are in place
E.g.: wrong site surgery, retained foreign body after surgery etc
62
Significant event:
-Formal process to review incidents that had or could have significant impact on pt care. Can be positive or negative, can offer learning opportunities
E.g.:
--> delayed diagnosis that lead to pt harm
--> successful resuscitation due to excellent teamwork
63
What is a near miss
incident that coiuld have caused pt harm but was prevented before it happened
64
What is a datix
incident reporting system used in healthcare to record and manage pt safety events
65
Swiss cheese model
-Accidents happen when multiple layers of defense (safety measures) fail.
66
How to differentiate infected pancreatic collection
-Gas in collection
-Procalcitonin
67
Blood test to always remember in abdominal pain
amylase
preg test
68
Management of bullying
Management with bullying
-might not feel comfortable speaking to cons if junior registrar
-Educational supervisor and clinical supervisor
-training programme director
-chief exec + GMC
-Document all issues
-Speak to colleagues to see if they also feel unsupported
69
Pt unhappy with managment
-Reassure
-Apologise
If still unhappy:
-Refer to pals, inform consultant/line manager
70
Bleeding patient
TXA
Are they on any anticoagulants in hx
71
Post operative complication
DIscuss in M and M
72
M and M
-Mistake: e.g. wrong antibiotic prescribed, pt allergic to antibiotic
-Post operative complication
73
Have to leave theatre
Think about my training needs
74
Dont say 'I want a CT scan'
Say CT abdomen and pelvis with IV contrast
75
Differential diagnosis for iscahemic bowel
-SMA thrombus
-Internal Hernia
-Closed loop obstruction
-Ischemic Colitis especially in elderly patients
-mesenteric ischemia,
-Non Obstructing Mesenteric --Ischemia (Hypoperfusion due to hypotension-Critically ill patients),
76
Unwell patient/trauma patient
Ensure trauma call put out/in safe environment (resus)
77
Splenectomy patient
Discuss conservative, surgical, IR manageement even if pt is unstable in scenario and it seems obvious
78
Trauma patient resuscitation strategy
Permissive hypotension (70-100mmhg)
79
When would CT be indicated in pancreatitis late phase?
To check for complications from day 7 in patient persistently spiking temperatures/not improving
80
When would CT be indicated in pancreatitits early phase?
-Uncertain diagnosis: inconclusive bloods
-Concern for alternative diagnosis: perforation, mesenteric ischaemia
-Severe or woresening course (signs of necrosis: can develop early but usually sterile in first few days)
81
Epigastric pain
Don't forget chest infection and MI--> trop
82
Indication for appendicectomy overnight:
-Very high inflammatory markers
-Fever or tachycardia
-Perforated or gangrenous appendix on CT
83
If delaying sending for patient due to other patient:
-Send someone to review the patient to make sure they're worked up for theatre and ok
-Apologise to the patient and advise them of the situation
84
Trauma patient location considerations
Is this a major trauma centre? if not will need transfer
85
Trauma patient ATLS
C: secure C spine with collar and blocks
A
B: oxygen
C: catheter, tranexamic acid, crossmatch 4 units, ECG (theatre), major haemorrhage protocol
D: Glucose/pupils/gcs
E: analgesia, NGT if vomiting/perforation, CT trauma series
86
Post op patient examination and charts
Examine:
stomas, wounds, drains, lines, legs
-case notes, operation note, observation, fluid balance, anaesthetic chart, drug chart
87
Organisational issues: difficulties with colleagues
-Consider factors which may be causing the difficulty
-Patient safety: should be supervised at all times during clinic/on call shifts
-Other people may be having the same issue
-Gather information: other registrars working with same person, predecessor
-Escalation pathway: ed/clinical supervisor, clinical lead, tpd, medical director, Chief exec, BMA, GMC
88
How to resolve training issues
-Define training objectives in PDP: definine operations and level of competency, how you plan to achieve it
-D/w rota coordinator to ensure assignment to good lists
-Speak to colleagues and ask about their learning needs
-Explain start by gaining competency with port placement, instrument handling, relevant anatomy
-Speak to the Consultant and senior registrar about your learning needs and emphasise that you need to gain exposure to this procedure to progress in your training. Explain that you would like to assist them first during the procedures and learn their technique (highlight the value of teaching a junior colleague).
Suggest measures to ensure the list finishes on time and without complication e.g. handing the procedure over to the senior registrar if you are taking too long or if you are having difficulties.
Escalate
89
Reasons why ST6 colleague might not want to let you operate:
-They want to complete a higher number of these procedures to progress in his training
-they do not feel comfortable supervising a junior colleague without a Consultant present
-they are under pressure to finish the list on time.
90
Specialties to escalate to
-Radiology: ask to hot report
-Own consultant
-ITU
-Haematology: jehovah's witness, anticoagulant, antiplatelet)
-Paediatrics (if child)
91
Jobs to delegate to SHO/resus nurse
-Bloods/access
-Catheter
-Discussing with specialties
-Calling radiology
92
Paediatric trauma patient
Transfer to paediatric trauma centre
93
Not answering bleep: factors to consider
-May be unwell
-bleep may not work/may not know how bleep system works
-May be busy with ward patient
-May be overwhelmed and needing support
94
Management station ccrisp
Say won't go into detail as management station
95
Ending of management station
-Debrief
-reflection
-Support
-ISCP logbook
96
Anyone likely needing surgery
-PMHx
-Medications ? anticoagulants
-Social history
97
Clinic setting needing surgeyr:
Say would book into preassessment clinic
98
AF
Remember medical management and speak to medical team
99
Ischaemic bowel escalation:
Talk to vascular
100
Thrombus management
\Start IV heparin
101
Other specialty not seeing patients
-Call them yourself: talk reg to reg
-Escalate if necessary to my consultant and to bed manager
102
Diabetic patient with abscess
-Ensure on sliding scale
-Review abscess for signs of nec fasc like crepitus, spreading cellulitis, necrosis/change in colour
103
SBAR handover for pseudoaneurysm
S: -CT angio confirmed pseudoaneurysm
B: IVDU
A: clinical status, what you've done
R: WHat the plan is
104
Management of pseudoaneurysm
Conservative, medical, surgical
Conservative:
--> small pseudoaneurysm: US monitoring
Medical:
--> US guided thrombin injection
Surgical:
--> stent
--> debridement + stent if infected
105
Discharging laparotomy wound
Probe to check sheath intact
Send swab for MC+S
106
Hyperkalaemia
-Insulin dex
-Calcium gluconate
-Salbutamol nebs
-Escalate medics
107
Ward round entry unsatisfactory (didn't see discharging pussy wound)
-Did they review wound
-Feedback to person who did w/r
108
Have to communicate with patient about wanting to self discharge
SPIKES
Setting: ask staff for privacy, anyone else needed?
Perception: patients perception of situation: e.g. ask if they know how serious the condition is
Invitation: how much do they want to know: "is it ok if we talk about some serious issues about your care?"
Knowledge: deliver the news
Empathy
Summary/strategy
109
Never events
-Wrong site surgery
-foreign body retained after surgery
-Death/serious disability from incorrectly administered medication
110
Not enough training issues (nurse and ons don't want to teach)
-Patient safety: i need to be competent
-Factors why they might not teach: don't want to risk complications, reluctant to teach, under pressure to finish on time
-Nursing staff: want to finish on time, previous negative experiences (complications, long procedures)
111
Resolving lack of training
--> PDP: targets and how to achieve
--> speak to rota coordinator to assign to good lists
--> Speak to other trainees to determine training needs (ST8 complex, me simple)
--> speak to other trainees ? how did they maximise opportunities
--> speak to cons on list
--> start with small steps to gain their confidence (port placement, relevant anatomy)
--> offer ways to speed up list, e.g. handing over to cons if taking long
Escalation:
--> list cons, ed/clincal supervisor, clinical lead, surgical tutor, TPD
112
Lazy colleage issues: ST7 not wanting to do discharge summaries
-Pt safety issues
-Additional work may impede my training
-consider contributing factors: does not know how to do them, too senior to complete them, busy with other work
113
Lazy colleague actions
-Ensure pt safety issues are resolved within competency
-Information gather with colleague in non confrontational manner, focus on pt safety
-Suggest solutions: show them how to do the tasks, offer to share workload if reason they can't do
-If difficulty: escalate
Escalate to:
--> AES, CS, consultant in charge of clinic, clinical lead, surgical tutor, TPD
114
High number of complications, wanting to remove patients from M and M issues
-Pt safety issue
-Probity issue if not presenting certain complications
-Contributing factors: high risk procedures, high risk patients, lack of experience with certain procedures, bad luck
-Factors for not sharing M and M patients: inappropriate cases selected by me, desire to conceal complications from colleagues
115
High number of complications, not wanting to present M and M cases initial actions
-Gather data: review specific complications over last year compared with other consultants, review previous M and Ms, incident forms, complaints
-Hold informal discussions with team members to determine if they hold similar views
-Speak to cons about reasons for not including cases
-Seek advice from AES, clinical supervisor
-Present findings to consultant in the department responsible for clinical governance
-Escalation pathway: cons, AES, CS, clinical lead, medical director, chief exec, BMA
116
Escalation pathway
Non training issue e.g. cons with lots of complications: AES, CS, clinical lead, medical director, chief exec, BMA
Training issue: AES, CS, clinical lead surgical tutor, TPD
117
Uncontactable Fy1, has been rude to nurses, coming to work late, not finishing jobs on time, uncontactable when pt unwell issues
-Pt safety
-Poor performance increasing workload of others
-Factors to consider: lack of awareness, personal issues (relationship issues, mental health problems, substance abuse)
118
Uncontactable Fy1, has been rude to nurses, coming to work late, not finishing jobs on time, uncontactable when pt unwell solutions
-Ensure unwell pt didn't come to harm
-Gather information from nurses/fy1
-Give advice: prioritisation and sharing of workload
-Ask them to apologise to nurse
-Encourage them to apologise to nurse
-May have to escalate to ed/clinical supervisor to determine how to proceed e.g. greater workplace superision, compassionate leave, couselling with personal issues
SPIES
-Seek information
-Patient safety
-Initiative
-Escalate
-Support
119
Rota gaps issues: have to cover to detriment of training. ST8 refuses to cover on call shifts
-Training compromise: need to gain surgical experience
-May be at risk of fatigue
120
How to resolve issues rota gaps
-Team meeting with rota coordinator and other registrars
-Highlight how it can be beneficiao to do on call shifts for experience in appendicectomy, laparotomy, hernias
-Determine how many gaps in rota exist and when registrars will return (if ever)
-If not enough registrars to staff rota then there is clear case to employ more staff at next clinical governance meeting
Escalation pathway:
--> AES, CS, Clinical lead, surgical tutor, TPD, medical director, chief exec, BMA/GMC
--> exception reporting, report to guardian of safe working
121
Unsupported by consultant, uncontactable during lap appendix issues
-Should be supervised during on call shift
-Other registrars may also be working unsupervised
-Factors which may contribute: phone may be off, phone may not be working, choosing not to answer work calls
122
Unsupported by consultant, uncontactable during lap appendix Actions
How to resolve:
--> Speak to other registrars about working with this cons ? established practice
--> Speak to predecessor
--> speak to cons in question
--> highlight specific issue of not being able to contact for emergency procedure
Escalation:
--> AES, CS, Clinical director, surgical tutor, TPD, Medical director, chief exec, BMA/GMC
123
Staff grades getting all the theatre time
--> Staff grades are employed for service provision, not training
--> Could ask to join their lists as training opportunity, assist them initially and perform steps
124
Consultant bullying colleague, I have just started working at new hospital
-Reassure colleague, clarify situation and if this has happened beffore
-Advise them to raise issue with clinical supervisor/aes
-Speak to other doctors about experience with this cons
-Speak to predecessor about experience of working with this cons
-May not feel comfortable speaking to cons as junior reg: raise with clinical supervisor and/or aes who should be able to address
Escalation: AES, CS, clinical lead, surgical tutor, TPD, medical director, chief exec, BMA, GMC, MDU
125
On call: Fy2 is struggling with number of referrals, nurse in charge said Fy2 was rude over phone. unwell patient in resus not been reviewed Issues
-Pt safety: unwell pt in resus
-Factors why f2 may be not seeing referrals: overwhelmed by workload, being unable to priortise tasks or delegate effectively
-F2 has been rude to colleague over phone which is not acceptable
126
On call: Fy2 is struggling with number of referrals, nurse in charge said Fy2 was rude over phone. unwell patient in resus not been reviewed. How to resolve:
--> arrange to meet f2 in ED, speak to nurse in charge about surg referrals
--> arrange to see patietns in order of priority with Fy2, start with unwell pt in resus.
--> use each clinical review as possible teaching opportunity
--> once patients have been seen and stabilised, ask f2 to take break and offer to hold bleep so they are not disturbed
--> After on call speak to fy2 about difficulties they faced, make suggestions about how they can prioritise patients and delegate tasks to fy1s
--> encourage Fy2 to apologise to nurse in charge of ed to ensure future good working relationship
--> Encourage Fy2 to write reflective entry and speak to clinical supervisor/aes at next review
127
Orthopaedic injury
-Assess peripheral vascular status
-Think compartment syndrome if crush injury
128
Any conflict situation priority
In any conflict situation priority is to gather information
129
CT2 arriving late:
Ask someone to stay behind `
130
Trauma patient
Note distracting injury
Say would look for other injuries as well
Haemodynamically unstable: think of pelvic injury
If high mechanism of injury: high injury severity score
131
Compartments of the leg:
-4 compartments: Anterior, lateral, superficial and deep posterior compartments
Fasciotomy incisions:
--> done at bedside
--> full length incision 2 fingers breadth lateral to tibia
--> Posterior: 2 fingers medial to tibia
132
Management station priority:
-Sickest patient with your specialist skills
133
AAA referral from another hospital
--> Send images to vascular consultant
--> Explain have lots of sick patients and ask them to assess images and arrange transfer
134
Paediatric safeguarding issue
Safeguarding officer
135
Mum consents but dad saying no
-Gather information : home status, fathers input, mothers input. Explain think operation is suitable but happy to discuss
-Safeguarding officer
-Ask them to bring legal documents: if legal mother on birth certificate, can consent
-Gillick competence
-Ultimately priority for myself and patient is to ensure best care for patient
136
Patient needs operation as emergency but can't speak english
-Consent 4
-If staff member that can speak language: can document on the consent 4
137
Capacity:
Understand
Weigh up
Retain
Communicate
138
Conflict:
-'in my experience, conflict comes from miscommunication and a lot of these can be solved by speaking to the patient and their relatives
139
What do you plan to do if you don't get a number question:
-Work as registrar
-Say have discussed with consultant at busy DGH, happy to have me for another year
140
Impact factor:
-Calculated from mean yearly citations
-Used as proxy for relative importance of a journal within its field
141
Umbilical hernia
Size of defect >4cm: needs mesh
142
Anastamotic leak in patient with defunctioning stoma
Can me mx non operatively
Later date: ct with rectal contrast to check anastamosis has healed
