A Core Surgical Training (CT1) station on MedMock, start to finish

Hello, thank you for joining us. This is the Management and Clinical station. I'll give you one management scenario and then two clinical scenarios, one at a time, and you have about five minutes for each. Here's the management scenario. You're a core surgical trainee in general surgery. Your consultant is operating on the first patient on an elective list and rings you from theatre. They ask you to go to the admissions lounge and consent the next patient, a 67-year-old man listed for a laparoscopic right hemicolectomy for a caecal cancer. The operation was discussed with him in clinic, but the consent form was never completed. You've never seen this operation done and you don't know its specific risks. What would you do?

Thank you. The central issue is that this man is about to have a major cancer operation, and he's entitled to make that decision with proper information: the benefits, the risks that matter to him, the alternatives, and the chance to ask questions. The form is only a record of that conversation. GMC guidance on consent is clear that whoever has that conversation needs enough knowledge of the procedure and its risks, and I don't have that for a right hemicolectomy. So I shouldn't consent him, however busy the list is. But I also don't want to just say no and leave my consultant with a problem, so I'd do three things. First, I'd be honest on that same phone call: "I'm happy to help, but I've never seen a right hemicolectomy and I don't know its risks well enough to consent him. Could the registrar or you see him between cases? I'll have everything else ready so it doesn't hold the list up." Second, I'd still go and see him. I'd introduce myself, read the clinic letter so I know what he was told, check his observations, bloods and group and save, and ask whether he's had the information leaflet and what questions he has, and I'd write those down for whoever consents him. I'd be straightforward with him: a surgeon who does this operation will come and go through it with him properly. Third, I'd tell the theatre coordinator and the anaesthetist that he isn't consented yet, so he isn't sent for before that's done. The sign-in on the WHO checklist should catch it anyway, but I wouldn't rely on that. And I'd ask if I could sit in when he's consented, because this is a gap in my knowledge that I should close.

Your consultant replies: "It's all in the leaflet. Just get the form signed and I'll go through it with him in the anaesthetic room." What do you do now?

I'd stay polite, but I still wouldn't get it signed. I'd explain briefly why. If he signs after talking to someone who can't answer his questions, that isn't informed consent, and Montgomery is clear that it's about a dialogue on the risks that matter to him, not getting a signature on a form. The anaesthetic room isn't the place to have that discussion for the first time either: he'll be anxious, on a trolley, with the team waiting, and it's very hard for anyone to say "actually, I'd like to think about it" at that point. So holding back protects him, and it protects my consultant as well. Then I'd offer the practical fix again: the registrar could see him while the first case is being closed, it would take ten or fifteen minutes, and everything else will be done. Framed as a solution rather than a refusal, most consultants will accept that. If they still insisted, I'd make sure he wasn't sent for until a surgeon who could consent him had seen him, and I'd let the theatre coordinator know. I wouldn't have an argument over the phone in front of the theatre team; I'd ask to talk it through with my consultant after the list. And if being asked to consent for procedures beyond my knowledge turned out to be a pattern, I'd raise it with my educational supervisor.

Thank you. Let's move on to the first clinical scenario. You're the core trainee on call overnight. A nurse rings you about a 71-year-old man who is on day four after an elective laparoscopic anterior resection. His heart rate is 115, blood pressure 98 over 60, respiratory rate 24, saturations 95% on air and temperature 38.3, and he's alert. His NEWS2 is 8. How would you manage him?

A NEWS2 of 8 is in the high-risk band, so he needs an emergency assessment now. With a fever, a tachycardia and a raised respiratory rate I'm thinking sepsis, and on day four after an anterior resection that's an anastomotic leak until proven otherwise. On the phone I'd tell the nurse I'm coming straight away, and ask her to put him on continuous monitoring, call the critical care outreach team, and give oxygen if his saturations fall below 94%. At the bedside I'd use an ABCDE approach and treat as I go. Airway: he's talking. Breathing: his rate and saturations, and I'd listen to his chest, because a chest infection or a PE are on the list too. Circulation: pulse, blood pressure, capillary refill and his fluid balance. I'd put in two large-bore cannulae, send blood cultures, FBC, U&Es, CRP, LFTs, clotting and a group and save, and do a venous gas for lactate. I'd give a crystalloid fluid bolus and reassess, start broad-spectrum IV antibiotics according to the trust guideline within the hour, and catheterise him to measure his urine output hourly. Disability: his conscious level and a glucose. Exposure: I'd examine his abdomen for peritonism, look at the wound, any drain, and the stoma if he has a defunctioning ileostomy, check his cannula sites and calves, and do an ECG. I'd make him nil by mouth and read the operation note to see how low the anastomosis is and whether it was defunctioned. I'd call my registrar early rather than once I've finished, because if this is a leak he'll need a CT of his abdomen and pelvis with contrast and a senior decision about theatre. And I'd explain to him what's happening and document everything.

His lactate is 4.2. After a fluid bolus his blood pressure is 84 over 50. Your registrar is scrubbed with another emergency and can't come for at least an hour. What now?

He's not responding to fluid. A lactate over 4 and a systolic below 90 after a bolus mean he needs critical care review now. Strictly, he isn't in septic shock until he needs vasopressors to keep his mean arterial pressure at 65 or above with a lactate over 2 despite adequate fluid, but that's the direction he's heading. So I'd give a further bolus and reassess, watching for fluid overload, ask the outreach team or the ITU registrar to see him now about vasopressors and a critical care bed, and make sure his antibiotics are in. With the registrar in theatre, this is exactly when I should phone the on-call consultant surgeon directly. I'd say: "I'm the core trainee on call. I'm calling about a 71-year-old man on day four after an elective laparoscopic anterior resection. He's septic, with a NEWS2 of 8, a lactate of 4.2 and a systolic of 84 after a fluid bolus. I'm worried about an anastomotic leak. He's had cultures and antibiotics, he's catheterised and ITU are coming to see him. I'd like you to come in, and I need your decision on CT or theatre." Then I'd keep resuscitating him with the outreach team. I wouldn't send him to CT until he's stable enough and escorted by someone who can manage him, and that's a joint decision with the consultant and ITU. If it's a leak with peritonitis he's likely to need theatre, so I'd give the on-call anaesthetist and the theatre coordinator an early warning. And I'd explain to him, and with his permission his family, that he's become more unwell and what we're doing about it.

Thank you. Final clinical scenario. A 24-year-old woman is referred to you from the emergency department with a day of right iliac fossa pain. How would you assess and manage her?

My first question is whether she's unwell: I'd check her observations and NEWS2, because if she's septic or has generalised peritonitis the pace changes completely. Assuming she's stable, I'd take a focused history: when the pain started, whether it began centrally and moved to the right iliac fossa, loss of appetite, nausea and vomiting, fever, and bowel and urinary symptoms. In a young woman I'd take a gynaecological history as well: her last period, any vaginal bleeding or discharge, contraception and whether she could be pregnant, and I'd ask those questions in private. On examination I'd look for localised tenderness and guarding in the right iliac fossa, signs of peritonism, and tenderness elsewhere. Investigations: a urine pregnancy test, whatever she tells me about contraception, and a urine dip, and bloods including FBC, CRP, U&Es and a group and save. A risk score such as the Adult Appendicitis Score helps me judge how likely appendicitis is and whether she needs imaging. For a young woman I'd use ultrasound first, which can look at the ovaries too, and keep CT for when the diagnosis is still unclear and pregnancy has been excluded, discussed with my registrar. The main differentials are appendicitis; gynaecological causes such as an ectopic pregnancy, ovarian torsion, a ruptured or haemorrhagic ovarian cyst or pelvic inflammatory disease; a urinary tract infection or a right renal stone; and less commonly Crohn's disease. If it's appendicitis, I'd keep her nil by mouth, start IV fluids and antibiotics, and discuss her with my registrar for a laparoscopic appendicectomy, with proper consent.

Her urine pregnancy test is positive, and she's haemodynamically stable. What now?

That changes things. With abdominal pain and a positive pregnancy test, this is an ectopic pregnancy until proven otherwise, although appendicitis is still possible: it's the commonest non-obstetric surgical emergency in pregnancy. First, I'd tell her the result privately and sensitively. She may not know she's pregnant, and she may not want whoever is with her to know. I'd ask about vaginal bleeding, shoulder tip pain and feeling faint. I'd keep her in, make sure she has a cannula, send an FBC, a group and save and a serum hCG, and keep her nil by mouth. I'd refer her urgently to the on-call gynaecology team the same day for a transvaginal ultrasound to find where the pregnancy is, and let my registrar know. Until that's clear, I'd make sure one named team is responsible for her, so she doesn't fall between surgery and gynaecology. If the pregnancy is in the uterus and appendicitis is still a concern, the imaging changes: ultrasound first, and MRI rather than CT if that's inconclusive. Any surgery would involve the obstetric team and the anaesthetist. And I'd make sure the nurses know what to watch for: if she becomes tachycardic, hypotensive or peritonitic, that could be a ruptured ectopic. That's an emergency: call for help, two large-bore cannulae, crossmatch and the major haemorrhage protocol if needed, the gynaecology registrar and consultant straight away, and theatre.

Thank you, that's the end of the station.