Post operative complication

Location: You are a junior doctor on ward cover for General Surgery over the weekend

Patient: Nursing staff have called you to review a patient who has had surgery 7 days ago, has started vomiting today and looks ‘not right’. The patient is a 30 year old male, since his operation he has generally not been feeling well. The day team have been treating him for post operative pain. He started to develop some bruising on his scrotum which eventually spread to his abdomen. You see the blood tests from 3 days ago show a Hb change from 160 to 70 over the space of a day, there was no action taken with regards to this. His observations are stable. You notice the patient is now yellow and has a bilirubin of 70. A CT scan was reported after hours but it does not appear anyone has acted on it. You have reviewed the operation note showing an inflamed appendix and haemostasis achieved before closure.

CT scan result:
There is relatively high attenuating fluid within the pelvis and the paracolic gutters. Within the pelvis, the fluid collection measures 15x10x5 cm and demonstrates internal heterogeneous high attenuation areas. The overall CT appearance is concerning for intraperitoneal blood products. There remains some inflammatory changes around the right caecum but no definite organised collections are seen. No generalised free intraperitoneal gas. No bowel obstruction. The lung bases are clear.

Task:
– Discover what the patient already knows
– Explain the most recent CT scan result to the patient
– Answer any questions that the patient may have

Note to actor: Try to restrain yourself from volunteering too much information – you may do so when prompted (that is, by a specific question, not a general one). If a student is on the wrong line of clinical reasoning do not fuel this line of thinking, state no to the question as being ambiguous may prompt further questioning and does not allow the student to be appropriately tested. The aim of the exercise is to take a focused history; short answers may be required.

Overall role = you are frustrated that you have not been told what is going on. You desperately want to go back to France but you cannot travel at the moment. You have been doing everything that the doctors have been saying but you seem to be getting worse. You do not understand any medical jargon and require it to be explained if said by the candidate. You need to give the candidate opportunity to break down this station, you are required to give very long pauses in order to make the station uncomfortable. Make use of non-verbal cues if appropriate to show sadness e.g hands on face covering eyes, shaking of head, ect.

You are a 30 year old French patient who speaks fluent English, who was admitted 7 days ago with right lower abdominal pain. You were told you had appendicitis and were taken to theatre the same day. The day after you were sore but you were told this is to be expected after an operation.

Since then you noticed a black spot on your scrotum which has spread to your abdomen. It is growing bigger by the day. You were told that you would need to be given some blood to “top you back up.” You have had lots of pain killers and this has helped with the pain.

You went for a scan yesterday but you have not been told anything about this.

This morning you had some toast and then started to feel nauseous, you are just feeling awful and have vomited 4 times. You are unable to keep down any fluids.

When you are told the result of the CT scan you are incredibly frustrated that you have been kept in hospital so long and you have been getting so unwell and you have had to wait so long to have an answer about this. Each day you have been telling the doctors that you do not feel right but nothing has been done.

All you want to do is fly back to France but you keep being told you aren’t ready. You are very happy with your doctor in France, you have known them all your life and you just want to go home. You have no friends or family here. You feel very isolated and alone. Your family are unable to come to you are they are concerned that you have been in so long. After your brother has his appendix removed he was discharged from hospital the next day.

Questions you want answering:

1. Was there a complication with the surgery? (you do not let this go with a vague answer, you want a yes or no answer and what the complication was)
2. Can you fly back to France? (again you want a yes or no answer, if no you need a reason why. If the doctor says you are free to leave if you sign a discharge against medical advice then you apologise and explain you are frustrated and want to get better
3. What did the CT scan show?
4. What is going to happen after you see me?
   

If the candidate appears to have finished early remind them how long is left at the station and enquire if there is anything else they would like to ask, or whether they have finished. If they have finished, please remain silent and allow the candidate that time for reflection.

Score