Post operative complication


  • Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

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.

Category Question
Done
Excellent
Introduction Candidate appropriately introduced themselves with:
Full name
Medical school / year / grade
Clarifies who they are talking to
Asks patient for preferred name


Introduction
Gains consent for consultation
Mentions confidentiality
Explains context of consultation - consultant called away urgently / not available
Asks if patient has brought anyone else along to the consultation


Pre-knowledge Assesses what the patient already knows
Asks for events leading up to now
Discovers what patients knows about operation
Asks about care after surgery
Candidate summarises the situation so far


Delivery of information
‘Warning shot’ - e.g, “i am here to talk about your scan done yesterday and it’s not good news.”


Information
Provides information in a sensitive but clear manner
Explains presence of blood in abdomen


Chunks information
‘Chunks’ information to check patient has understood


Time
Provides patient with time to process information
Does not try to fill the silences


Complication
Explains complication occurred
Blood in abdomen
Known complication


Plan
Provides sensible plan to patient
E.g discuss with senior / consultant on-call
NBM / Repeat bloods


Avoids jargon
Avoids medical jargon


Patient space
Provides patient with time to process information / does not try to fill the silences


When delivering information:
Candidate allows patient to lead consultation (does not talk endlessly to fill silence)
Does not attempt to solve problems
Listens and responds appropriately to cues


Following information
Responds appropriately to non-verbal cues - e.g, “you have been very quiet, what are you thinking about”
Displays appropriate empathy


Candidate explores:
Emotions related to conversation
Recognises and validates concerns


Closing consultation
Checks patient understands the plan going forward
Makes appropriate arrangements for follow up / contact about further discussion


Patient score
Good rapport with patient
Active listening skills
Appropriate use of body language
Avoids medical jargon
Logical structure / does not jump around topics in consultation
Summarises and checks patient understanding



Score