HELPING YOU

INVESTOR THROUGHISSUE
NEWSLETTER YOUR CORE SURGICAL INTERVIEW
N°3 2016
FALL 2005

Core Surg ic al
Inter v iew Guide 2016 5th Edition

The Guide for the Core Surgical Interview

Core Surgical Training

Core Surgical Training in the UK Ranking for your CT1 job matters. If
you get a high enough rank to be given 2
i s a t wo ye a r p ro g r a m m e or 3 of the sub-specialities of your
SECTION 1 designed to provide junior choice, or indeed the themed job of your
CLINICAL choice, then you are setting yourself up
Past stations with mock answers surgeons with general operative
with a great chance at that ST3 number.
given at interview by candidates. skills, clinical experience of both If you just scrape into core training then
Advice on how to approach the acute and ward based surgical you have to take what you are given, and
question, communicate your may not be able to do your chosen
care, and to introduce trainees to
k n o w l e d g e e f f e c t i ve l y a n d
supplementary clinical a range of sub-specialities. By the
information to make revising for end of CT2 you will have
the clinical station easy completed 24 months in surgery,
a prerequisite for progression to
SECTION 2
PORTFOLIO ST3 level.
Optimise your portfolio and
make it stand out, and impress
The structure of training varies
your interviewers. Prepare for
the new format of the portfolio throughout the country but
s t a t i o n i n c l u d i n g p re p a re d normally comprises of 4 or 6
presentation station.
month rotations. These are
Supplementary questions from
recent inter views on your themed in some deaneries such as
specialty before ST3 interviews. Clearly
portfolio with advice on how to in Manchester where a core you would be at a disadvantage to the
best answer them trainee will do around 18 months candidate above who has already got 6
months of experience and project
of one speciality and 6 months of completion.This is why we encourage all
SECTION 3
MANAGEMENT another, or varied, like in London applicants to put every effort into
The dreaded management station preparing for the interview. It may be too
where you do 4 month rotations
made simple. Past stations with late now to publish another paper, but it
in CT1 and then two 6 month is not too late to polish your interview
useful structures that you can use
rotations in CT2, one of which technique, and read up on the topics
w h e n f a c e d w i t h d i f fi c u l t
commonly asked. The Core Surgical
questions. Our authors, who all will be the sub-speciality of you Interview Guide aims to make this
previously went through the choice. process easier for you by providing a
interview take you through structure with which you can answer
common questions, and advise questions, through in depth discussion of
you on how to score maximum At the end of Core Training you the questions that we were asked over the
points apply to Speciality Training, ST3- last few years.

ST8, which leads to a

ISBN: 978-0-9576100-3-3 We aim to demystify the core surgical
Certification of Completion of application, and provide relevant advice
Training (CCT), allowing you to on how to prepare for the interview. The
stations provided here follow the actual
become a Consultant. format you will experience at interview,

CORE SURGERY INTERVIEW GUIDE www.surgicalinterview.co.uk

 HELPING YOU THROUGH YOUR CORE SURGICAL INTERVIEW 2016

A P P L I C AT I O N GUIDE
CONTENTS PAGE

CONTENTS 105-108 How to structure your portfolio

3 About us 109 Writing the perfect Curriculum Vitae
CLINICAL STATION 110-111 Portfolio overview
4 Introduction to the clinical station 112-113 ePortfolio
5-8 Elderly woman with a fall 114 2 minute leadership biography
9-11 Painless haematuria 115 Publications, presentations and audit
12-14 Post operative pyrexia 116-117 Teaching and audit
15-17 Wound dehiscence 119-127 Commitment to specialty
18-20 Epistaxis 128-129 Research and audit
21-24 Loin pain 130-131 How to critique a paper
25-27 Bowel obstruction I
28-31 Bowel obstruction II MANAGEMENT STATION
32-34 Burns 132 Introduction to the management station
35-36 Slipped upper femoral epiphysis 133-134 Consultant appears drunk at work
37-39 Trauma 135 Conflict Resolution
41-42 Hip dislocation 136 Dealing with colleagues
43-45 Breakdown of anastomosis 137-138 WHO checklist
46-50 Abdominal pain 139-140 Risk stratification
51-53 Projectile vomiting 141-142 NCEPOD
54-57 Difficulty urinating 143 Sterilisation
58-60 A painful leg 144 Decision making
61-63 A neck lump 145-146 Rota dispute
64-67 Shin pain 147-148 Data Protection
68-70 Penetrating trauma 149 Nurse practitioners
71-73 Post CABG complications 150 European working time directive
74-77 Swollen testicle 151 Incidence and prevalence
78-79 Paediatric hernia 152 Screening
80-82 Epigastric pain I 153-154 Medical ethics
83-85 Child with a fracture 155 Statistics
86-88 Post operative confusion 156-157 Clinical governance
89-91 Wounds and dressings 158-159 Consent
92-95 Epigastric Pain II 160 Taking the initiative
96-98 RTA 161 Revalidation
99-100 Post operative assessment 162 Cancelled theatre list

PORTFOLIO STATION 164 CONCLUSION

101-104 Introduction to the portfolio station

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 HELPING YOU THROUGH YOUR CORE SURGICAL INTERVIEW 2016

ABOUT US

We are a group of surgical trainees,

working in London. We have all been
through the Core Surgical application
process, all ranking highly, and all
successful in getting our top choice
jobs.
We began writing down some of the
questions and themes that have come
up in recent years, adding advice to
those applying in the future. The
result, is the Core Surgical Interview
Guide.
It did not exist when we applied and
the only way of getting this advice
was by asking those who had gone

INTRODUCTION score, they are separated by their ahead of the competition as you
application for m score. The walk into your interview.
National Recruitment application form therefore gives the
Standardisation of the interview
All core surgical training portfolio station panel another
means that no matter where you
applications are now centralised source of information to form their
are being interviewed they should
and run by via the www.oriel.nhs.uk questions from, but does not
be testing the same skill type, be
website. This means you only have necessarily contribute to your
that decision making, clinical
to submit one application. This ranking.
judgment or academic
portal is now used for all specialty
The centralisation of the achievement. Therefore you can
applications. Important
application process aims to make it learn from people who have been
information specifically about core
fairer by standardising selection through it before you, and predict
surgical applications can be found
across deaneries. The old boys’ the type of question you will be
at www.surgeryrecruitment.nhs.uk
network no longer influences who asked. They change the stations
2011/12 was the first year that gets in. Today, each application e a c h ye a r, a n d d u r i n g t h e
England, Wales, Scotland and form and interview question must interviews, from day to day, but
Ireland was accessed through a be validated to show that it truly is practicing similar stations is by far
single application process. In the selecting out the best candidates. the best way to prepare for your
application form you list your interview. The panels have a
The application form is relatively
deanery preferences. Candidates moderately sized question bank of
straight forward compared to what
are guaranteed one interview at validated questions that they vary
you will be asked at ST3 level.
their top preference deanery. If you subtly from interview to interview.
However, it allows the deaneries to
are successful you will be contacted
place you into general categories. We have included sample interview
and requested to sub-preference the
Excellent, Good, Average, and questions here. They will not be
programmes/job combinations
Below Average. Do everything you exactly the same, as the deaneries
available. Core surgery posts are
can to ensure that you are in the may change them, however, we
allocated based on your overall
‘excellent’ category on your encourage you to practice them
ranking. This is based on your
application form so that you are more than once, to place yourself a
interview score. However if two
step closer to your CT1 job.
candidates have the same interview

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 HELPING YOU THROUGH YOUR CORE SURGICAL INTERVIEW 2016

THE INTERVIEW

CLINICAL

CLINICAL STATION The clinical station consists of in an organised fashion. There is no

questions in a short case format, guarantee that any interviewee will
Introduction which form the basis of a general have covered a particular specialty
The clinical station of the interview discussion around the topic. The during their training to-date. The
process can cause most angst for number of questions that you are panel will be looking for a
applicants. How can you prepare asked will depend on how quickly candidate who can give accurate
for this without revising the whole you answer the questions and and confident answers, but also
of the oxford handbook? It is worth anecdotally at least, being asked someone who can be structured
33.3% of the marks available; the many, or very complex questions, and logical in their reasoning and
same weighting as the management especially towards the end of your presentation, as well as importantly,
and portfolio stations. It is feared station, means that you have done demonstrating that they are a ‘safe’
because for some this will be one of well and the panel are trying to doctor.
the first experiences of an oral differentiate a good candidate from
In one of the author’s interviews he
clinical examination Whilst a an excellent one.
was asked about orthopaedics, a
written examination allows you to
The questions will test your clinical speciality he had no experience of.
sieve through your thoughts to
knowledge and should be scenarios Despite this he did well as he was
reach a conclusion, oral
that are commonly encountered by able to answer the questions in a
ex a m i n at i o n s p re s s u r i s e t h e
a surgical SHO on call. It is sensible structured way.
candidate into immediately
unlikely therefore that you will be
revealing those thoughts. The key The interviewers are looking for
examined on very uncommon
to this station is therefore to take a logical, structured thinkers, who
presentations, injuries or diseases.
moment, answer questions clearly will be able to cope with the
You are assessed on the structure of
and logically, and practice, practice, demands of a surgical career, rather
your answers and your clinical
practice. The course will polish than a preformed surgical registrar.
knowledge. Structured answers,
your answers to the clinical That said, practicing the clinical
even when lacking some of the
scenarios rather than teach you the stations that commonly come up
more challenging clinical details or
knowledge required so try to read should allow you to prepare. We
differentials, will mark you out as
all the cases before hand. have included some of them here.
someone who thinks logically and

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Clinical Station
An elderly woman with a fall
You are called to A&E to see an 88 year old woman who was found lying on the floor halfway down the corridor
in her nursing home. At baseline, she has a poor level of mobility, only being able to mobilise around 15 yards
with zimmerframe. She does not recall having a fall, but another resident saw her trip and fall, holding her left
hip afterwards. She currently complains of pain in this hip and on examination the hip is shortened and
externally rotated. She is in some pain at rest, and this increased on attempts at passive movement of the hip.
On your general inspection, you note that she has a pacemaker in situ.

The following radiograph was performed by A&E.

What would be your assessment of this patient’s injury and her x-

ray?

The main differential diagnosis consistent with this presentation is a

fracture of the neck of femur and although I want to see two views,
the radiograph presented is consistent with an intertrochanteric
fracture of the left femur.

Supplementary note
The history could also suggest an anterior dislocation of the hip, which could cause a restricted range of motion
and pain on passive and active movement. However, only 10% of dislocations are anterior and whilst the limb is
externally rotated, it tends not to have the same degree of external rotation as in cases of neck of femur fracture.
A posterior dislocation, which would be more commonly sustained after this type of injury, the femur would be
shortened, but internally rotated, unlike this case.

What are the risk factors of this kind of injury?

This injury seems to have been associated with minor trauma according to the collateral history, which in the
majority of cases points to someone with weakened bone. (Most hip fractures in patients with physiologically
normal bone are the result of high velocity injury). The most common bony weakness is due to osteoporosis,
followed by metastatic deposits, metabolic bone diseases such as Paget’s and osteomalacia and more rarely,
osteomyelitis.

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Clinical Station
An elderly woman with a fall

How would you manage this patient initially?

I would assess and manage this patient according to the ATLS ABCDE protocol, making patient safety my
primary concern. She should receive adequate analgesia according to the WHO pain ladder. This is likely to
include the prudent use of opiates, taking into account her age and co-morbidities. I would also ensure that my
patient was suitably fluid resuscitated using either a colloid or crystalloid solution depending on local guidelines.
At this time she should have two wide bore cannulae in situ, bearing in mind the blood losses that can occur from
a femoral fracture. The neurovascular status of the leg should be assessed and documented before any
interventions take place. I would also make this patient ‘nil by mouth’, in anticipation of a surgical intervention,
at this time I would ensure she had maintenance fluid prescribed. In the meantime, her leg should be placed in a
‘foam gutter splint’ for comfort and to reduce the risk of pressure sores. As she will have reduced mobility for a
period of time, she should have mechanical and chemical thromboprophylaxis; TED stocking and low molecular
weight heparin, unless contraindicated.

What investigations would you order for this patient and what role would they have in your management?

Important bedside investigations include a urine dip to check for signs of a urinary tract infection, which could
precipitate a fall in the elderly. I would order two views of the affected bone or joint. In this case, I would order
an AP pelvis, and a lateral right hip x-ray and full length femoral views. Pre-operative work up of this patient
would include full history and examination, importantly determining the nature of the fall (mechanical or
secondary to an underlying pathology), any co-morbidities, and the identification of any additional injuries.I
would take routine bloods and add a clotting screen and a cross match of two units of blood. Depending on the
length of time the patient was on the floor, a creatinine kinase may be indicated. I would also order an ECG and
CXR as this would help in my assessment of this patient’s anaesthetic risk and identification of underlying
pathology that may impact on their ASA classification. I would also request a pre-operative pacemaker check.

What would be the surgical management options for an intertrochanteric fracture?

I would manage this type of injury with a dynamic hip screw, followed by fluoroscopic images taken throughout
the repair to ensure the maintenance of the fracture in satisfactory reduction and proper positioning of the
fixation device.

Supplementary information
Intertrochanteric fractures are inferior to the joint capsule and lie in the plane between the greater and lesser
trochanter. Despite a reportedly acceptable rate of healing rate with conservative methods, surgical intervention
has replaced previously prevalent methods of prolonged bed rest and traction in a spica cast, each of which also
carry their own risks. Surgical intervention is now most common.

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Clinical Station
An elderly woman with a fall

What additional complications can result from intracapsular fractures of the femoral head and how would you
manage one of these injuries?

The femoral head in the adult has a retrograde blood supply with blood vessels running from the capsule and
along the femoral neck. Displacement of the femoral head and traumatic disruption of the capsule can cause a
disruption of this vasculature. This can lead to the problems of avascular necrosis of the femoral head, as well as
malunion.
Treatment options vary, depending on the age and mobility level of the patient. I would take a full patient and
collateral history concerning premorbid state and level of function. If she had limited mobility before sustaining
the fracture, I would look to perform a hemiarthroplasty. I would have a choice of cemented and uncemented
methods of securing the implant to the femoral shaft. This method would allow early mobilisation once her pain
score allowed it and I would ensure that appropriate post operative analgesia was prescribed to this end.
Functional outcome of hemiarthroplasty in patients with limited mobility tends to be satisfactory. I would ensure
that thromboprophylaxis was not forgotten, as the risk of venous thrombosis, possibly with progression to
pulmonary embolism, would be considerable.

How would your management differ in a younger, more active patient?

Intracapsular injuries in young patients would be more commonly associated with

high impact injuries such as RTA and sporting injuries. My initial management
would be to assure haemodynamic stability using an ABCD approach, with
assessment of the airway, breathing and circulation before consideration of bony
or ligamentous injury. I would proceed to open reduction and internal fixation
once the patient was cardiovascularly stable. I would also note that the incidence
of AVN in younger patients are considerable, with some studies noting rates of
up to 20% and ensure that this was explained to the patient and included on their
consent form.

Supplementary Information

You should be familiar with Garden’s classification of fractures. This is the classic method of neck of femur
fracture description, although it is becoming outdated
Type I: stable fracture with valgus impaction
Type II: Non displaced, complete fracture
Type III: Displaced fracture with maintenance of ‘end to end’ contact between the two bony fractures
Type IV: Completely displaced fracture with no contact between bony fragments
Type III and IV are associated with an increased incidence of AVN

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Clinical Station
An elderly woman with a fall

Management can be remembered easily - 1,2 screw (fixation with a

cannulated screw), 3,4 Austin Moore (or rather they will normally
require hemiarthroplasty to avoid AVN)

Sub-trochanteric fractures occur through or distal to the

trochanteric line in a transverse orientation. These are not
manageable by plate fixation, but are commonly managed with
intramedullary nailing. Rehabilitation and thrombosis prophylaxis
are as previously described.

Advice

The danger this question, where you may have some knowledge and experience, is the temptation to tell the
examiner all that you know about neck of femur fractures in general, rather than answering the question posed.
In this example, the case surrounds a plain film of an intertrochanteric fracture and the specific management of
this injury. You should answer the question you are asked and then stop. If they want more the examiner will ask
further questions. It is best to be guided by them, rather than trying to include all the knowledge you in an
answer, as you need to focus on where the points are. Examiners are generally helpful and will ask you a more
focused question if you have not scored all the points.

One strength of this answer is the appropriate exhibition of further reading of current literature, with regards to
the rates of AVN in young patients with neck of femur fractures. If you can include something similar in your
answer you will mark yourself out as one of the top candidates. Only do so if it flows naturally from your answer.
However, do not forget the importance of covering the important aspects of what you actually would do as an
SHO; a full history and examination, ensuring that the patient is haemodynamically stable, appropriate
investigations , prescription of analgesia and LMWH etc... These are equally important, give structure to your
answer, and show that you have actually been on the wards and will be a safe surgeon.

Here we have included extra information in the answers for your information. The examiner may wish to have a
more unstructured discussion about a topic, especially if it concerns his/her specialty. In this case, the examiner
is probably trying to stretch you, and it is your opportunity to distinguish yourself as an excellent, rather than just
a good candidate.

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Clinical Station
Painless Haematuria
You are asked to see a 69 year man who has been referred from his GP with painless macroscopic haematuria
with some clots. He denies urinary frequency or dysuria, but has noticed around 7kg of unintentional weight loss
over the past 4 months. He worked in a chemicals factory for 25 years, but is now retired. He has an 80 pack year
history.

What would be your differential diagnosis?

Painless haematuria in an individual of this age, and with a history of unintentional weight loss often suggests an
underlying malignancy; Frank haematuria has a 20% rate of revealing a urological malignancy. My main
differential would be bladder cancer, especially given the additional detail about the gentleman having worked in
a chemicals factory for 25 years. His history of smoking and occupational exposure to chemicals such as amines
from the textiles industry are known risk factors for transitional cell bladder cancer. Notably, 90% of bladder
cancers present with haematuria.

I would also consider renal carcinoma. This would classically be associated with loin pain +/- an abdominal
mass and I would take a more detailed history and fully examine the patient to fully assess this likelihood. There
is a possibility that this could be prostatic in origin or related to a bladder stone, but these often would be related
to microscopic, rather than macroscopic haematuria. Cystitis would also be a possible cause of this bleeding, but
was be less likely given the patient’s gender, as well as his lack of dysuria and urinary frequency.
Pain is usually associated with an inflammatory process and its absence in this case would make a renal or
bladder stone less likely and the length of the history together with weight loss point away from infection as a
cause.

How would you examine this patient?

Patient safety is my primary concern, and I would assess the patient clinically using the ABCDE protocol. I
would determine the extent of blood loss and ensure that the patient was haemodynamically stable. I would
complete with an examination to exclude abdominal and suprapubic masses and a digital rectal examination to
examine the prostate. One would also palpate for the bladder to assess for retention, as blood clots (or a tumour)
may cause an outflow obstruction. In this case a wide bore urinary catheter with the option for saline irrigation
may be indicated.

What investigations would you arrange for this patient?

I would perform a bedside urine dipstick test to confirm the presence of blood and subsequent urine microscopy
test to rule out infection. Microscopy may also identify malignant cells.
(Urine tests allow an initial assessment of the risk of urological malignancy, however overall sensitivity is less than
75% for medium and low grade tumours.)

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Clinical Station
Painless Haematuria
CT KUB, or intravenous urogram (IVU) in some hospitals, will identify the structure and function of the urinary
tract, as well as identifying stones in either ureter, while ultrasonography will allow visualisation of the renal
parenchyma.

Flexible or rigid cystoscopy under general anaesthetic currently represents the gold standard in assessment of the
structure of the bladder and would allow identification and treatment of a bleeding site, along with a biopsy or
resection if necessary for histological diagnosis.

If a tumour was identified in the urological tract, a computed tomography (CT) staging scan would be
appropriate to assess the extent of muscular invasion and any metastatic spread.

What would be the treatment if bladder cancer was identified?

It is important to involve the MDT in all cases of malignancy, and of course, all options should be discussed with
the patient. Following appropriate imaging, a transurethral excision may be carried out. CT scanning would
allow staging and identification of distant metastases, with further treatment options dependent on staging.

Supplementary information
Low grade tumours are treated by transurethral resection of bladder tumour (TURBT) followed by long term
outpatient cystoscopy screening. High grade tumours are also managed by TURBT if possible, followed by
chemotherapy, for instance single dose of intravesical chemotherapy or a weekly dose for 6 weeks after surgical
procedure. All such decisions are made after discussion between surgical and oncological teams in the uro-
oncology MDT.

Invasive bladder cancer (T1-T4) can be managed by partial or radical cystectomy with pelvic lymphadenectomy
and urinary diversion (either continent or incontinent), external beam bladder irradiation or systemic
chemotherapy. Metastatic bladder cancer (as identified by CT scan) would be primarily managed by a cisplatin
based chemotherapy regimen. It would be essential to start this as soon as possible, as untreated metastatic cancer
has a 2-year survival rate of less than 5%.

How would you decide which patients to refer to urology?

I would refer any patient above the age of 50 years presenting with microscopic haematuria or patients of any
age with frank haematuria for specialist urology opinion to exclude the possibility of urological malignancy.

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Clinical Station
Painless Haematuria
Supplementary Information

Staging of Bladder Cancer

The classical TNM system can be combined to calculate an overall cancer stage. Bladder cancers are staged from
I to IV, from least to most serious.

Stage
Stage 0a Non invasive papillary carcinoma with no invasion into bladder connective tissue or the muscle of the bladder wall.
(T0, N0, M0) No lymph node or distant spread

Stage I Carcinoma spread into the layer of connective tissue under the lining layer of the bladder but no bladder invasion.
(T1, NO, M0) No lymph nodes or distant sites.

Stage II Carcinoma spread into bladder muscle wall, but no breach of the muscular layer into fatty layer surrounding the
(T2a or T2b, bladder. No lymph nodes or distant sites
N0, M0)

Stage III Carcinoma spread through the bladder muscular wall into surrounding fatty tissue. Possible prostatic, uterine and
( T 3 a , T 3 b , vaginal spread. No pelvic or abdominal wall spread. No lymph node or distal spread.
T4a, N0, M0)

Stage IV (T4b, N0, M0): Carcinoma growth through bladder muscular wall and into the pelvic or abdominal wall. No
lymph node or distal spread.
(Any T, N1-3,M0) Carcinoma spread to nearby lymph nodes (N1-3), but no distal spread
(Any T,any N,M1) Spread to distal sites, such as lungs, liver or bone (M1)

Advice

You do not need to remember the details of the TMN classification of bladder cancer, but be aware of how if
influences management. This answer concentrates on the differential diagnosis as appropriate for the history.
When answering questions on differential diagnoses it is important to be specific, and not list every differential
you know. However, concentration on the details of the case, namely the occupational and smoking history, as
well as gender, allows you to be more specific. While cystitis is a legitimate cause of macroscopic haematuria, to
mention it before urological malignancies would show an absence of logical thinking and perhaps would signal
that if you were faced with this case as an admitting CT1 doctor, there could be some delay in initiating
necessary investigations to identify and treat malignancy.

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Clinical Station
Post operative pyrexia
You are asked to see a 67 year old with a 40 pack year smoking history and a previous diagnosis of COPD. He is
one day post repair of a strangulated, indirect, right inguino-scrotal hernia. He has a productive cough and a
temperature of between 37.9 degrees and 38.6 degrees over the past 8 hours. He is tachycardic at a rate of
110bpm and has a respiratory rate of 21 with saturations of 96%. His pain score is 5/10.

What is the most likely cause of this gentleman’s tachypnoea, pyrexia and tachycardia?

The most likely cause is a postoperative pulmonary atelectasis secondary to the accumulation of mucus secretions
in the bronchial tree. This is a risk after any intra-abdomial or thoracic surgery, where coughing will exacerbate
pain by increasing intra cavity pressures. The risk is magnified in patients with pre-existing pulmonary disease.
Pyrexia so soon after surgery is unlikely to be due to wound infection, however a pneumonia, pulmonary
embolism and DVT should be considered. In addition, other sources of infection such as a UTI, perhaps from an
indwelling catheter, cellulitis, pressure sore or other open wounds should be in one’s mind, and a comprehensive
examination would aim to identify these.

Which factors could be responsible for these complications?

Pre-operative factors include his pack year history and prior diagnosis of COPD which would contribute to
excess mucus production and collection in his bronchial tree and would reduce his functional respiratory reserve
and effective alveolar exchange surface. A smoking history also makes him more susceptible to infection.

Peri-operative factors, such as the gases used in a general anaesthetic and intubation irritate the respiratory
mucosa and increase mucus secretion from mucosal goblet cells, as well as a small amount of oedema as a post
inflammatory response to the endotracheal tube. The muscle relaxant used in general anaesthesia can reduce
post operative inspiratory effort. Being mechanically ventilated causes alveolar barotrauma, making one more
susceptible to alveolar collapse. Lying prone for the operation can result in a ventilation/perfusion mismatch,
increasing the likelihood of atelectasis. If the procedure involved laparoscopy, then the insufflation of CO2 results
in a splinting of the diaphragm and reduced ventilation to the lung bases.

Post operatively, the pain of the groin incision, lying prone, increased sedation and reduced mobility could inhibit
clearance of the accumulated secretions, increasing the likelihood of alveolar collapse.In addition, the chances of
developing aspiration pneumonia, are increased. This most commonly occurs 5 days post operatively.

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Clinical Station
Post operative pyrexia
Advice
It is appropriate to group risk factors into pre-operative, operative and post operative providing a good structure
to hang your answer on. Remember: “categorise to survive!”

How would you examine this patient and how would you proceed to management?

I would start by ensuring that the patient was haemodynamically stable with assessment of the airway, breathing
and circulation following ALS principles. If the patient was speaking to me, I would consider his airway as being
patent. I would percuss and auscultate the chest and carefully inspect for use of accessory muscles, signalling
respiratory distress. I would assess the patients pulse and BP and look for a raised JVP, which could be a sign of
congestive cardiac failure secondary to an MI.

If I was worried about the patient’s current clinical state, I would contact my registrar, preferably from the
operating team, to review the patient. I would ensure that the patient had two wide more cannulae in situ, with
fluids running as necessary. I would request a chest x-ray and review the most recent blood results, including
inflammatory markers and sputum culture for the patient. I would also take an arterial blood gas (ABG) and send
blood cultures and an MSU and blood cultures. It is important to send these before starting any antibiotic
therapy.
I would monitor the patient’s saturations and if below his pre-morbid baseline in the medical notes, would start
low dose oxygen by nasal cannula, taking care of the history of COPD and the importance of not suppressing
the hypoxic drive and worsening his symptoms. In the acute setting I would prioritise satisfactory oxygenation,
but monitor for CO2 retention by repeating an ABG 30 minutes after commencing oxygen.
If I suspected pulmonary embolism was the diagnosis, I would organise a CTPA. (A d-dimer blood test would be
of limited use as a raised result may represent generalised inflammation post operatively, rather than a
thromboembolism.)

It is important to involve the respiratory physiotherapy team early in this patient’s management. Vigorous
breathing exercises and chest percussion would clear secretions. I would review his analgesia and if necessary
liaise with the pain team, as managing his pain more effectively encourages a more effective cough. This could be
managed by regular oral analgesia or patient controlled analgesia (PCA) as required. Finally, if the blood results
or cultures suggested any signs of infection, I would commence antibiotics according to local protocol, after
taking appropriate microbiology guidance.
If I were particularly concerned about his oxygenation, it may be prudent to contact the ITU outreach team or
anaesthetic registrar for advice ± review.

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Clinical Station
Post operative pyrexia
Advice

It is important to answer the question asked of you. On this occasion the question is “what is the most likely
cause of this gentleman’s symptoms”. Therefore begin your answer by saying the most likely cause and your
reasonings. You can then go on to talk about important differential diagnoses to consider, and the examiner can
stop you if this won’t score you any points.
This is a fairly typical presentation that will be managed initially by many FY1s post operatively. The difficulty in
this question is answering in a systematic manner. It is useful when asked about complications post surgery to
categorise your answer. In this case, we have used pre-operative (intrinsic to the patient him/herself), peri-
operative and post operative. This lets the examiner know that you are a logical thinker, and acts as a memory
aid. You will find that you build up a bank of these aide memoirs and that your answers become more structured,
the more you practice using them. There are more examples of these throughout this guide. Do not forget to
mention that you would contact your seniors in a situation such as this. It may sound straightforward, but it is
good practice to contact senior support early on, even if you will be managing the case mostly by yourself in the
early stages, your seniors should be aware of any concerning cases on their take. The multidisciplinary team has
become an integral part of our practice, so mention it when appropriate, including keeping the ward nurses up to
date so that they can help you hang fluids, will take more regular observations etc... It shows that you are on your
way to becoming a rounded surgeon and a good team member.
One of the key factors the examiners are looking for is a good SHO who is not only being able to manage cases
with the knowledge that you have, but also to be able to call in the help of other health care professionals when
needed and to be aware of limitations.

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Clinical Station
Wound dehiscence
You are asked to see a 67 year old retired architect who had a right hemicolectomy through a right paramedian
incision for a carcinoma of the caecum. Post operatively, he had a prolonged period for paralytic ileus requiring
passage of an NG tube, and IV fluids. He passed flatus on day 6 post operatively. However, despite this, his notes
suggest ongoing abdominal distention. On day ten post operatively, after transfer to a general surgical ward, he
has a period of coughing and called the nurses because of pain in his abdomen and some pink fluid coming from
his wound. You are called to assess him.

What would you do?

Over the phone I would ensure that the essential initial steps had been taken, asking for the observations, the
patient’s symptoms and his current state, and assess what level of input was needed. If he were deteriorating, I
would ask them to get further help, for instance putting out a medical emergency call if appropriate, before
immediately attending the patient.

(You can immediately set yourself apart from the competition by picking up on the cue that you are being called to see him. Therefore
you can take the opportunity to show that you would want to get an impression of the patients current state and the urgency of your
review, as well as instigating a plan for the ward staff while they wait for you to get to the ward.)

I would proceed by assessing the patients airway, breathing and circulation, ensuring they were
haemodynamically stable. , I would reassure the patient and ensure that appropriate analgesia was prescribed. I
would contact my senior colleagues as this patient has signs of wound dehiscence and potentially needs to be
returned to theatre for wound exploration under a general anaesthetic.

(The ‘pink fluid sign’ described here is produced by serous peritoneal exudate, tinged with blood and hence pink in colour which oozes
through a breaking down abdominal wound, sometimes for a number of days. It is a warning sign before complete wound dehiscence.)

You leave the patient to try and contact your registrar. However, you are then
called to a cardiac arrest which you have to attend. You return to the patient 90
minutes later to find a distressed patient complaining of a ‘lump coming from his
stomach. The patient is in moderate discomfort.

How would you proceed?

I would re-assess the patients airway, breathing and circulation and treat as
required. I would reassure the patient whilst examining the abdomen to determine

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Clinical Station
Wound dehiscence
I would give the gentleman adequate analgesia together with an antiemetic to prevent opiate induced retching
that could result in more bowel escaping from the abdomen. I would ensure my registrar and consultant were
aware and prepare the patient for theatre, liaising with theatre staff, ward staff and the anaesthetist team.

Would you attempt to reduce the bowel on the ward and if so, how would you do this?

I would not attempt to reduce the bowel. The rigidity of the abdominal wall would not allow this, it may cause
damage to the bowel and it may be extremely painful. I would cover the exposed viscera with a sterile towel or
large dressing soaked in warm normal saline and keep this in place with a bandage if necessary. I would then
fast-bleep my registrar immediately and ready the patient for surgery. This would include ensuring that a valid
group and save was available, that the patient was consented for theatre, and that the time of last eating and
drinking was documented. This patient needs immediate transfer to theatre.

What factors could be responsible for this emergency?

A numbers of factors could impact optimal wound healing. These include pre-operative, peri-operative and post
operative factors.

A patient with pre-existing co-morbidities, such as anaemia, jaundice, malignancy, vitamin C deficiency, diabetes
or protein deficiency would have impaired skin healing and a higher risk of wound breakdown. Smoking is also
an important risk factor for poor wound healing.

Peri-operatively, poor surgical technique or surgical error can play a significant role. Sutures can be placed too
close to the wound edge, with poorly tied knots, the suture ends cut too close to, or indeed cut through the knot.
Increased bowel handling intraoperatively can increase oedema of the bowel and intra-abdominal pressure,
putting tension on the closure. Any leakage of bowel contents, or other contamination of the wound, will impair
wound healing.

Post-operative factors increasing the risk of wound dehiscence include patients with chronic cough, for example,
those with chronic bronchitis, increase their intra-abdominal pressure and cause increased tension on suture lines.
The same would apply to patients with high body mass index, and patients with constipation. Infection at the
surgical site is also an important factor in poor wound healing.

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Clinical Station
Wound dehiscence
What is Jenkins rule?

This is a rule for closure of the abdominal wound. It states that for a continuous suture, the length of suture used
should be at least four times the length of the wound with sutures 1cm apart and with 1cm bites of the wound
edge.

How should this wound be repaired?

The patient should be placed in the supine position under general anaesthesia. Firstly any non viable tissue
(including peritoneum and rectus fascia as necessary) around the wound edges should be debrided. Repair
should be carried out using interrupted nylon sutures, which are passed through all layers of the abdominal wall,
all layers of the rectus fascia muscle and peritoneum, but not including the skin. including the skin. The sutures
should be held open until all are inserted, as this improves the accuracy of suture placement and then each one is
tied one after the other in series, taking care not to damage underlying viscera.

If the deep layer of the abdominal wound gives way, but the skin sutures stay intact, what is the diagnosis?

An incisional hernia

Supplementary information

Numerous studies have shown the benefit of the ‘mass closure’ technique of suturing the abdominal wound. All
layers of the abdominal wall apart from the skin and subcutaneous tissue are picked up a minimum of 1cm from
the wound edge on either side and the sutures inserted 1 cm or less apart. The skin is closed as a separate layer.
This gives the maximal strength to the abdominal wound, reducing the risk of dehiscence. The suture material to
repair the abdominal wound should be non absorbable (e.g.: nylon) or only slowly absorbable (e.g.: PDS) material
and should not be too fine. Size 1 is commonly used.

Advice

The supplementary information here is useful knowledge, but not essential to answer the question. The question
about ‘Jenkins rule’ again was meant to stretch the candidate here and you would not necessarily be expected to
know that. The key again here is structure. You can see that this answer benefits from using the distinction
between pre and peri/post operative risk factors and this gives the answer some direction. It may seem repetitive
to keep answering questions with basic life support diktats and in many cases, your examiner will let you skip over
that to the specifics of the question. However, it shows that above all, you are safe. Again, notice the early
involvement of senior help. This patient will need surgical intervention and whilst your role is not necessarily
going to be to provide that help directly yourself, especially in the early stages of your training, the good CT1 will
facilitate the most optimal management for the patient as quickly as possible.

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Clinical Station
Epistaxis
You are called to see a 55 year old office manager, who is on warfarin for atrial fibrillation. He presents to A&E
with profuse epistaxis. He is a known hypertensive and has a history of congestive cardiac failure. Examination
shows active bleeding from the right nostril.

What is the likely differential diagnosis and what further features of the history are important?

There are local and systemic causes, but the majority of cases of epistaxis have no underlying pathology. and are
secondary to trauma, often minor trauma at the area of congenitally fragile blood vessels known as Littles area
(Kiesselbach's plexus). Pathological causes include impaired coagulation, secondary to drugs such as warfarin or
antiplatelet agents, diseases of the bone marrow or liver. Although local trauma (or a nasal neoplasm) could
present with unilateral epistaxis, this would not be profuse unless it disrupted the wall of an artery.

I would ask about previous episodes of epistaxis and whether he had a history of bruising or bleeding elsewhere
on his body. I would also query whether he had a history of local trauma which could explain the episode.

How would you proceed?

My priority would be to arrest the haemorrhage and stabilise the patient. I would start by assessing this
gentleman’s airway, breathing and circulation as appropriate. I would immediately resuscitate the patient if I
believed him to be clinically shocked. This would involve assessment of his pulse, blood pressure, respiratory rate
and an estimation of blood loss. If the patient was shocked, I would ask a member of the nursing staff to put
firm pressure on the cartilaginous section of the nose using my finger and thumb, whilst I alerted my senior
registrar to the details of the case and contacted the ENT registrar. I would then establish intravenous access,
take blood including FBC, clotting and group & save and start to resuscitate the patient if necessary using colloid
or crystalloid solutions.

If the patient was not shocked, I would sit him up, with his head titled downwards to prevent blood passing
posteriorly. I would put firm pressure on the cartilaginous section of the nose using my finger and thumb. After a
period of 10-15 minutes, I would pack the nose with a nose pack or simple gauze if no other material was
immediately available. Ideally I would use a substance such as bismuth iodoform paraffin paste under local
anaesthetic cover.
My first priority it to ensure that the patient is safe. This involves assessment using the ATLS ABCDE protocol. If
I were concerned about the safety of his airway due to the flow of blood I would put him flat in the head down
position to reduce blood flow into the airway and contact the anaesthetists. I would also contact my senior and
the ENT registrar in this situation.

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Clinical Station
Epistaxis
I would assess the level of blood loss and determine whether he was clinically shocked. If this were the case I
would contact my senior. I would ensure that he had two wide bore cannulae in situ, taking blood including
FBC, clotting and group & save and start to resuscitate the patient if necessary using colloid or crystalloid
solutions.
If appropriate, direct pressure over the cartilaginous section of the nose using finger and thumb can help to
reduce blood flow. An ice bag on the forehead at the top of the nose can help to promote coagulation and reduce
blood flow.
If the patient were not clinically shocked, then sitting him up, with the head leaning forwards helps to prevent
blood from flowing posteriorly.
I would want to put nasal packs in place to reduce the bleeding if simple measures did not work. Ideally I would
use a substance such as bismuth iodoform paraffin paste under local anaesthetic cover.
If a single bleeding point were identified, this could be chemically cauterised using a silver nitrate stick, but this is
unlikely to be successful in a patient with a pathological bleed, who is bleeding profusely, as in this case.

Would you need to admit this patient?

All patients with packing would require admission. They are at risk of hypoxia, and inhalation of packing
substances, and therefore it is advisable for them to be in hospital where they can be monitored. This would also
be a chance to investigate the underlying cause of the bleed; in this case it is likely to be due to an elevated INR.
The patient may need surgical intervention to stop the epistaxis.

His INR result comes back at 4.5. How would you manage this?

In a patient who has a raised INR and is acutely bleeding, it is important to consider the reason that they are
taking the warfarin (e.g. AF vs mechanical heart valve), and the relative risks and benefits of stopping and/or
reversing anti-coagulation. For this reason, it would be advisable to discuss the case with the haematology
registrar, and my senior.
I would stop the warfarin, and could give vitamin K orally or IV to reverse the effects of the drug. In severe
bleeding this can be supplemented with fresh frozen plasma, prothrombin complex concentrate, or recombinant
factor VIIa, depending on the urgency of the situation.
If the patient were acutely bleeding I would stop the warfarin, immediately reverse it using prothrombin complex
concentrate (Beriplex/Octaplex) or fresh frozen plasma after discussion with the haematology registrar on call. I
would get further advice from the ENT registrar.

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Clinical Station
Epistaxis
Supplementary Information

Anterior epistaxis is commonly septal. It is invariably from the area of anastomosis between the sphenopalatine,
facial and ethmoidal arteries, known as Little’s area (Kiesselbach's plexus).

The first line for investigation for anterior epistaxis is rhinoscopy, performed by ENT specialists in most units.
Posterior epistaxis is not normally easy to locate by this method. The gold standard is to visualise the bleeding
point by nasendoscopy and then to treat directly, e.g with bipolar cautery.

If the bleeding point cannot be found, the nose is generally packed with gauze, which is then left for 48 hours.
Prophylactic antibiotics should be considered if the pack remains in situ for more than 48 hours. Toxic shock
syndrome is a potential sequelae.

Advice

It is important to realise that epistaxis can be fatal and should be taken seriously. You must discuss the potential
for hypovolaemic shock in this case, as well as your method of resuscitation. It would be fair to say ‘I would stop
the bleeding and then contact ENT specialists, especially if the patient is on warfarin. However, some knowledge
of the materials and methods involved in packing epistaxis and the anatomy of Little’s area will be more than
most candidates are able to achieve.

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 HELPING YOU THROUGH YOUR CORE SURGICAL INTERVIEW 2016

Clinical Station
Loin Pain
You are called to A&E and asked to see a 67 year old gentleman who complains of a 7 hour history of severe left
sided loin pain. On detailed examination, he reports a mild history of dysuria which has not bothered him
considerably. A urine dip is negative for nitrites and leucocytes, but shows microscopic haematuria. He has a
history of hypertension but admits to not having taking any antihypertensive medication for more than a year.
His blood pressure is 110/75 and his pulse is 113 bpm.

How would you proceed?

I would start by assessing the patient’s airway, breathing and circulation following the ABCDE ATLS principles
and commence resuscitation. If the patient was stable, I would perform a full clinical examination and take a full
history. From the history given, of tachycardia and a relative hypotension, I am concerned that the patient may
have signs of haemodynamic shock, and want to rule out a ruptured abdominal aortic aneurysm as a differential.
Specifically, I would feel for an expansile, pulsatile abdominal mass superior to the umbilicus. If I was concerned
about the likelihood of a ruptured aneurysmal sac, I would immediately contact senior surgical assistance to
assist in the assessment of the patient, and arrange an immediate CT with contrast. If available in accident and
emergency, an abdominal ultrasound may be helpful.

I would site two gray (16G) cannulae in the antecubital fossae, and send a set of bloods, including FBC to check
the haemoglobin, clotting to ensure it is normal, U&E to assess renal function, and I would cross match at least 4
units of blood. I would perform an ABG to obtain an immediate Hb and a lactate, which if high could point to
tissue ischaemia.

If I felt that his symptoms were more in keeping with renal colic, I could order a CT KUB to visualise his urinary
system and exclude obstruction.

What is the likely differential diagnosis?

There are a number of differential diagnoses in this case, such as ureteric colic, pyelonephritis and diverticulitis,
but the diagnosis that I would be most keen to exclude at an early stage is a ruptured abdominal aortic aneurysm,
which is associated with sudden deterioration and significant mortality.

Ureteric colic - pain comes in waves, unable to lie still

Ruptured abdominal aortic aneurysm - patient lying still
Pyelonephritis - renal angle tenderness & pain on ballotting
Diverticulitis - peritonitic, lower abdominal pain

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Clinical Station
Loin Pain
What features of the history would lead you to a specific diagnosis?

The most concerning feature in the history is his tachycardia and relatively low blood pressure. This gentleman’s
blood pressure, whilst within normal limits for a healthy young person, could be a sign of relative hypotension in a patient
with known untreated hypertension. Grade 2 shock, in a patient with severe abdominal pain should be considered as a
ruptured AAA until proven otherwise.
The patients gender, age and history of hypertension are risk factors for developing a AAA.

The diagnosis of ruptured abdominal aneurysm is commonly confused with renal colic. The pain of renal colic is
classically described as being relapsing remitting and the patient may demonstrate a waveform pattern with their
hands when questioned on the variation in intensity of the pain. Dysuria in a gentleman of this age would not be
exclusive to renal colic and could co-exist with a diagnosis of ruptured AAA. A patient with renal colic would
also classically be unable to lie still, classically differentiating it from the peritonitic picture of a patient with
perforated colonic diverticular disease.

Pyelonephritis would be less likely in this case, given the absence of fever, rigors, nausea or vomiting and it would
not explain the relative hypotension found in this case. Microscopic haematuria would not exclude AAA rupture
at the expense of renal colic in this case, mainly due to the age and gender of the
patient.

You review the patient’s past notes and find that a plain abdominal x-ray was
performed at his local hospital prior to transfer. What does this show?

This abdominal x-ray demonstrates the calcified wall of an aneurysm (arrowed).

It bulges over to the left side away from the inferior vena cava, which runs along
its right side.

You return from reviewing the x-ray to find your patient with a blood pressure of 85/45 and GCS 14/15. Blood
results are still pending.

What grade of shock does the patient have?

He is hypotensive and tachycardic, therefore he is in at least grade 3 shock.

This patient has clinically deteriorated and I would reassess using the ABCDE protocol. I would immediately
inform my seniors, the anaesthetist and theatres. It is likely that he requires urgent operative intervention.

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Clinical Station
Loin Pain
What further imaging methods would you use at this point to delineate the aneurysm?

Abdominal ultrasound is a useful and accessible imaging method and is used in population screening and in the
measurement of the AP diameter of the aneurysm. FAST (focussed abdominal sonography in trauma) scanning
can now commonly be performed in A&E resus departments. CT scan with intravenous contrast enhancement,
gives provides preoperative mapping of the aneurysm and detects associated aneurysms of the common and iliac
arteries. However, given the fact that the patient is showing signs of cardiovascular compromise, I do not think
transfer to the CT department would be appropriate at this stage.

What would you do?

I would aggressively fluid resuscitation and contact my senior colleagues and the anaesthetist to alert them to the
need for an immediate transfer to theatre for aneurysmal repair. It is important that the patient has 4-6 units of
blood available and two sites of wide bore access (grey cannula), whilst reassuring the patient.

Supplementary information

Grade Symptoms
1 Mild tachycardia
15% (750 ml) blood loss

2 Moderate tachycardia, fall in pulse pressure, delayed capillary return

15-30% (750 - 1500 ml) blood loss

3 Hypotension, tachycardia, low urine output

30 - 40% (1500 - 2000 ml) blood loss

4 As above but with profound hypotension

40-50% (2000 -2500 ml) blood loss

Shock:

Smoking and hypertension are the two risk factors for atheromatous aneurysmal arterial disease. The most
common site for aneurysmal formation is the infrarenal abdominal aorta. A variable length of the abdominal
aorta and the suprarenal abdominal aorta may be affected in 10-20 of patients, however the ascending aorta is
usually unaffected.

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Clinical Station
Loin Pain
Advice

The key in this case is recognition of a ruptured AAA as the most worrying differential in an older gentleman
presented with loin pain, with early signs of shock. This case has been used several times both for the core
surgical interview and in the MRCS part B. You must show an awareness of the severity of this diagnosis, in
terms of the significant associated morbidity and mortality. Discussion of assessment of airway, breathing and
circulation is essential. These patients are at high risk of rapid clinical deterioration and you must show that you
can identify the early stages of hypovolaemic shock. This question leads you towards a discussion of ruptured
AAA.

Whilst it is theoretically correct to list a number of differential diagnoses, it is a good idea to start your answer
with a sentence such as:

‘There are a number of differential diagnoses in this case, such as x, y and z, but the diagnosis that I would be most keen to exclude at
an early stage is a ruptured abdominal aortic aneurysm, which is associated with sudden deterioration and significant mortality’.

This leaves the examiner in no doubt that you have identified the red flag and that most importantly, you will be
a safe member of the team.

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Clinical Station
Bowel Obstruction I
You are asked to see a 72 year old retired army officer, living in a retirement home who was sent into A&E by his
GP. The patient reports a 3 day history of severe generalised abdominal pain, during which time his abdomen
has become grossly distended. He admitted to taking ‘a few tablets of codeine here and there’ for the pain, but
this has not led to any improvement in his symptoms. He has not opened his bowels since the start of this
episode, nor has he been able to pass flatus. He has felt nauseated for the past 24 hours, but has not vomited. He
has had a fall in appetite and he has not eaten properly for 2 days. His pulse is 95bpm with a BP of 170/90. His
temperature is 37.2 degrees. On examination, his abdomen was grossly distended and uniformly tender, with no
previous surgical scars and clear hernia orifices. He has no history of constitutional symptoms such as fever or
recent unintentional weight loss.

What could this patient have?

This patient appears to have a obstruction of his bowel as evidenced by the history of absolute constipation for
three days. The main differentials are:

1: Large bowel mechanical obstruction

2: Small bowel mechanical obstruction
3: Pseudo-obstruction (Ogilvie’s Syndrome)
4: Ileus

The history given for this patient makes a large bowel obstruction the most likely diagnosis; his constipation
preceded his nausea, he has not vomited and he has no evidence of previous abdominal surgery or hernia. Intra-
abdominal adhesions, from prior surgery or herniae are the two most common causes of an acute small bowel
obstruction in the UK. Obstruction of the small bowel would normally be associated with early or profuse
vomiting. The pain of small bowel obstruction is classically described as a ‘cramping’ pain, with each spasm
lasting a few minutes and vomiting precedes constipation.

How would you proceed?

After assessing the patients airway, breathing and circulation as appropriate, I would reassure the patient and give
him suitable analgesia, in this case most likely intravenous morphine. I would pass a nasogastric tube to
decompress the stomach and establish large bore IV access and start IV fluids. I would take bloods, including a
full blood count, U&Es, CRP, clotting, a group and save and a venous gas to check his lactate. I would also order
an x-ray of his abdomen whilst in the supine position, as well as an erect chest x-ray to rule out perforation.

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Clinical Station
Bowel Obstruction I

What does this abdominal x-ray demonstrate & is it supportive of your

diagnosis?

This x-ray shows a distended oval gas shadow, looped on itself to give the
typical coffee bean sign. The transverse markings of the dilated bowel do not
extend across the width of the gas shadow, suggesting that these are haustra
and hence this is large intestine. These appearances would be typical of
sigmoid volvulus.

How would you further investigate and manage this?

I would contact the registrar on call and make them aware of the patient I would take a full history and examine
the patient. This would include abdominal palpation and auscultation for bowel sounds, which would be
classically ‘tinkling’ in bowel obstruction. I would also take a set of bloods, including a venous gas and a lactate. I
would expect a metabolic acidosis and elevated lactate if there were bowel ischaemia. I would give IV fluids to
rehydrate and correct electrolyte imbalance and insert an NG tube to ensure adequate rest for the bowel.

The majority of patients with sigmoid volvulus can be effectively conservatively managed by decompression with
a rigid sigmoidoscope. This is passed with the patient lying in the left lateral position. A large, well lubricated, soft
rubber rectal tube is passed along the sigmoidoscope. The patient should then be observed for 2-3 days for signs
of bowel ischaemia.

How would you proceed if your attempts at conservative management were unsuccessful?

If the patient’s condition did not improve, that means their pain does not improved +/- raised inflammatory
markers and signs of sepsis, I would again contact my senior surgical colleagues. A loop of sigmoid, with its
blood supply cut off by torsion, is at risk of becoming necrotic if left untreated. I would prepare the patient for
theatre, and request urgent senior review. Preparations would involve a cross match of 4 units and insertion of
urinary catheter. Surgery would be carried out under general anaesthetic through a lower midline incision. A
rectal tube would be used to evacuate sigmoid contents and then the redundant sigmoid loop would be
commonly resected with immediate anastomosis or colostomy, depending on the fitness of the patient.

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Clinical Station
Bowel Obstruction I
Supplementary Information

Sigmoid volvulus occurs when the bowel rotates on its mesentery, with rapid development of strangulated,
obstructed bowel. The characteristic abdominal x-ray (shown above) shows ‘coffee-bean sign’, an inverted ‘U’
loop of bowel. Sigmoid volvulus is most commonly seen in the elderly, constipated patient (this gentleman has
been taking codeine) and those with notable co-morbidites and poor mobility (he is in residential home). It is
responsible for 8% of large bowel obstructions.
Ogilvies syndrome is an acute pseudo-obstruction and dilatation of the colon in the absence of true mechanical
obstruction. It occurs in severely ill patients and is associated with ‘massive dilatation of the caecum and right
colon on abdominal x-ray (>10cm). It may occur following major surgery, serious infection or metabolic
disturbance. It is also associated with drugs such as anticholinergics, which decrease colonic motility. However,
the exact mechanism behind its development remains unclear.

Note the use of the NG tube in obstruction. Simply being nil by mouth does not give adequate rest for the bowel
because the intestine can produce up to 9l of fluid/day.

Immediate surgery is indicated in cases of strangulation or ‘closed loop obstruction’. This can mean any bowel
obstruction where the bowel is obstructed at two points. In the small bowel the risk of strangulation is high with a
mortality rate of approximately 25%. It may also refer to the specific case of large bowel obstruction is associated
with a grossly dilated caecum. This occurs when the ileocaecal valve remains competent and does not allow
decompression of the large bowel retrogradely. The caecum dilates more than the rest of the colon due to its
larger diameter and there is a risk of pressure induced ischaemia of the bowel wall and ultimately, perforation,
One should therefore palpate over the caecum to assess for tenderness.

Advice

Bowel obstruction is a commonly encountered clinical problem and you will be expected to have some
experience of its management. Make sure that you are clear about the structural differences between small and
large bowel obstruction. Small bowel is identified by valvulae conniventes that cross the whole width of the
lumen, while the hautrae of large bowel do not cross the entire bowel width. Small bowel is usually more
centrally located on the AXR whilst large bowel is more peripheral. The key is to know how you would manage
the patient safely in the initial stages, placing a NG tube and giving IV fluid, as well as arranging suitable imaging
is a basic formula for safe initial management if accompanied by early involvement of senior colleagues and
analgesia as necessary.

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Clinical Station
Bowel Obstruction II
You are the surgical SHO on call. You are asked to see a 56 year old lady who has presented to A&E complaining
of sudden central abdominal pain which started 12 hours earlier. This started shortly after she had gone to bed
and was accompanied by one episode of vomiting. The pains recurred every few minutes and she vomited
green/yellow fluid a number of times. Since the pain began, the patient has not moved her bowels or passed
flatus. In terms of past medical history, this lady has had three previous spontaneous vaginal deliveries, she is on
HRT and had an open appendicectomy through a paramedical incision 10 years ago for a perforated appendix.

On examination, she has a temperature of 37.4 degrees and is tachycardic at 110bpm. She is clinically
dehydrated. On abdominal inspection, you see the following:

What is your chief differential diagnosis?

This lady has presented with acute colicky abdominal pain,

abdominal distention, profuse vomiting followed by absolute
constipation. These features are all classical for acute intestinal
obstruction. Her history of previous abdominal surgery, would
make obstruction secondary to adhesions or an adhesive band by
far the most likely cause of her symptoms. Early bilious vomiting
with later absolute constipation is associated with small bowel
obstruction.

What radiological investigations would help confirm your diagnosis?

I would request a plain radiograph of this lady’s abdomen. If I was concerned that she may have perforated
viscus as a cause of her pain, I would also request an erect chest x-ray, looking for air below the diaphragm.

Many radiographers are reluctant to perform plain abdominal x-rays. What are the other indications for a
plain film of the abdomen?

• Bowel obstruction
• Visceral perforation
• Acute inflammatory bowel disease
• Abdominal trauma
• Haematuria
• Renal calculus/renal colic

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Clinical Station
Bowel Obstruction II
These guidelines are to reduce the number of unnecessary abdominal radiographs being carried out, which will
not be helpful in reaching a diagnosis or influence management, in order to reduce the radiation dose given to
patients. However, in this situation, I feel that an abdominal x-ray would be wholly justified

This is taken from the current Royal College of Radiologists guidelines on abdominal x-rays. In addition the
following are not acceptable indications:

• Acute gastrointestinal bleeding

• Palpable mass
• Gallstones
• Pancreatitis
• Appendicitis
• Urinary tract infections
• Constipation (other than as detailed above)
• Non specific abdominal pain

What are the classical findings on x-ray in small bowel obstruction? What other imaging
would you like?

A supine radiograph of the abdomen may show dilated loops of bowel. Small bowel
would be centrally located and would have valvulae coniventes which pass transversely
all the way across the bowel. The maximum normal diameter of small bowel is 3cm.
An erect abdominal film may show multiple fluid levels, giving a ‘ladder’ pattern

I would also consider imaging of the abdomen after injection of water soluble contrast
through a nasogastric tube, an abdominal CT scan and abdominal ultrasound.

How would you manage this patient?

I would assess this patient’s airway, breathing and circulation and commence resuscitation as appropriate.
Although there is no evidence of blood loss, I would take note of her tachycardia and consider other causes for
this such as pain and sepsis.

I would reassure the patient and commence appropriate analgesia, and make the patient nil by mouth. I would
pass an NG tube and use suction to empty the distended stomach, review the patient’s blood results and do a

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Clinical Station
Bowel Obstruction II
antibiotic therapy if surgery was to be performed, after review of local protocols and discussion with
microbiology. I would discuss this patient with my senior colleagues and ensure they are prepared for theatre.

The patient failed to settle on conservative management and was operated on 48 hours later. Her abdomen
was explored through a lower midline incision. Distended loops of small bowel were immediately encountered.
An adhesive band was found across a loop of small intestine and to obstruct it. The band was divided and the
patient made a smooth recovery.

What are the complications of small bowel obstruction?

With proper diagnosis and treatment of the obstruction, prognosis in small-bowel obstruction (SBO) is good.
However, complications of SBO include sepsis and intra-abdominal abscess.
Cases requiring surgical management can be complicated by wound dehiscence, aspiration pneumonia (due to
poor clearance of secretions), short-bowel syndrome (as a result of multiple surgical interventions) and mortality
related to delayed treatment and perforation.

Supplementary Information

The leading cause of small bowel obstruction in the is postoperative adhesions in over half of cases, followed by
malignancy, Crohns disease, and hernias. Surgeries that are more commonly associated with small bowel
obstruction include colorectal and upper GI surgery, appendicectomy and gynaecological procedures.

A small proportion of patients with SBO will have no obvious abnormality on plain abdominal x-ray, possibly
explained by the loops of distended bowel being completely filled
maximum normal by fluid.
diameter

small bowel 30mm

Small bowel can dilate to approximately 5cm in diameter before it
large bowel 60mm
perforates. If you measure the diameter of a section of small bowel
caecum 90mm at 7cm, it probably isn’t small bowel.

Untreated, strangulated obstructions lead to an almost 10% mortality rate. If surgical management is
commenced within 36 hours, the mortality rate decreases to 8%. The mortality rate is 25% if the surgery is
postponed beyond 36 hours. In current practice, the majority of those diagnosed as having small bowel
obstruction are managed conservatively.

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Clinical Station
Bowel Obstruction II
Some adhesions from previous operations will loosen, leading to resolution of the mechanical obstruction.
Conservative management involves IV fluids, passage of an NG tube and correction of electrolyte disturbance. If
this route is taken however, the patient must have interval abdominal x-rays to ensure that the dilatation is not
worsening. Clinically, if the patient deteriorates, surgical intervention may still be necessary. Most cases do resolve
with conservative management in under 5 days.

Small bowel obstruction caused by IBD, radiation enteritis or following childbirth is rarely treated with surgery.
The converse is true for small bowel obstruction in an abdomen which has never been surgically managed. These
commonly require an operation to relieve the obstruction.

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Clinical Station
Burns
You are the surgical SHO on call. You are called to see a 52 year old factory worker who has sustained burns to
the his back and upper arms in an industrial accident.

How would you assess the severity of the injuries?

I would use the ‘rule of nines’ to assess the area affected. This states that the area of the front of the trunk is 2 x
9% of the body’s surface area, the back of the trunk 2 x 9%, each upper limb 9%, each lower limb 9%, the head
and neck 9% and the perineum 1%

or

I would use the patients open palm and fingers as representative of 1% of total body area and calculate the area
covered by the burns on this gentleman.

This gentleman total burn area was calculated as 14%. How would you initially manage this patient?

My first step would be to assess this gentleman’s airway, breathing and circulation. My main concerns would be
his airway as inhalational burn injuries can cause laryngeal oedema which can rapidly compromise an airway.
One would look for signs of inhalation, such as soot around the nostrils and mouth, or stridor. Additionally, I
would request regular reassessment of his GCS. Carbon monoxide inhalation can cause a delayed fall in
conscious level. I would contact my registrar and alert him to the situation.

14% burns area is borderline for intravenous fluid replacement. Current guidelines suggest that IV fluid
resuscitation is needed if the area of the burn is more than 15% of the total body surface area (10% in a child).

How would you calculate the amount of fluid required?

I would calculate this volume using the Parkland formula:

Fluid replacement in first 24hrs (ml) = 4 x weight of patient (kg) x % area of burn

Half of this volume would be given in the first 8 hours following the burn, and the second half over the next 16
hours. This would be in addition to the patient’s normal daily fluid requirements (3L of crystalloid fluid under
temperate conditions). My fluid of choice would be Hartmann's solution as it bears the closest relation to

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Clinical Station
Burns
What is the definition of a full thickness or partial thickness burn?

A partial thickness burn leaves part or whole of the germinal epithelium intact, so complete healing takes place.
A full thickness burn destroys the germinal layer and therefore unless it is very small, can only heal by dense scar
tissue.

This gentleman’s burns were found to be partial thickness on his back. The burns over the arms and his right
scapula were found to be full thickness. Would you refer this gentleman to a burns unit?

I would refer this gentleman to a burns unit as his injuries cover >10% of his body surface area

These areas of full thickness burns were excised the following day and covered with split-skin grafts taken from
the thigh. What types of grafts are in current usage?

A full thickness graft consists of the epidermis and the whole dermal depth. The donor site must be closed by
suturing or split skin graft.

A composite graft contains skin, cartilage or other tissue. This can be used to reconstruct specific areas with a
small surface area and unique structural needs, such as the nasal alar rim.

A split skin graft is taken through the germinal layer of the epithelium, leaving islands of the layer on the donor
site. It is a graft which includes the epidermis and a depth of the dermis. They would be useful in this case as
they can cover large surface areas and their rate of autorejection by the host is low. The donor site should heal by
re-epithelisation from the dermis and should be ready to be a donor site within 6 weeks.

Advice

Information on the management of burns is well covered in the ATLS manual. If you have not yet completed
the course, you will be able to get a copy of the latest manual from your library and it covers a number of useful
topics in some detail. It is important that you know the indication for referrals to a burns unit, (see
Supplementary Information), as well as how to figure out methods for fluid replacement and calculation of burns
surface area.

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Clinical Station
Burns
Supplementary Information

Indications for Referral to Specialist Burns Unit

• Partial thickness burns greater than 10% total body area

• Burns involving the hands, feet, face, genitalia , or major joints
• Third degree burns in any age group
• Electrical burns, including lightening injury
• Chemical burns
• Inhalation injury
• Burns injury in patients with co-morbidities that could affect recovery
• Any patient with burns and concomitant trauma (such as fractures) in which the burn poses the greatest risk of
morbidity or mortality.
• Burned children in hospitals without qualified personnel or equipment for the care of children
• Burn injury in patients requiring special social, emotional or long term rehabilitative support.

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Clinical Station
Slipped Upper Femoral Epiphysis (SUFE)
You are asked to review a 13 year old girl who is slightly overweight. She presents with her mother who explains
that her daughter has suffered a ‘groin strain’ and thinks that this must be due to playing netball, which she was
playing that afternoon. She first experienced pain in the groin 2 months ago and has been taking paracetamol,
but it has not improved. She is able to weight bear, but does this reluctantly, she is no longer able to take part in
netball training. The urine is negative for betaHCG.

What is your differential diagnosis?

The probable diagnosis in this age group and gender is of a slipped upper femoral epiphysis (SUFE). However,
the injury could be related to a simple muscular strain as suspected by the parent in this case. Perthes' disease is
less likely as it affects those aged between 3 and 11 (typically 4-7) with males more commonly affected.

Which factors on history and examination would support this diagnosis?

Males are more commonly affected with SUFEs, but it is associated with obesity in 50% of cases. It is associated
with pain in either the hip or the knee and a resultant antalgic ‘waddling gait’ and limp. Hip motion would be
limited, particularly involving internal rotation, the foot would be externally rotated and there could be apparent
shortening of the hip. In 20% of cases, SUFEs are bilateral. The classical case is in early adolescence, with boys
affected from 12-15 and girls from 10-13.

I would perform a detailed gait examination, paying particular attention to external rotation, (which would be
apparent even in early slips of the epiphysis) positioning of the foot whilst at rest and the range of active and
passive motion at the hip whilst lying supine.

Which investigations would you order?

I would order an AP pelvis and frog lateral view of both hips (as 20% of cases are bilateral), as well as the knee if
the patient complained of pain in this joint as well.

What are your treatment options for this patient?

I would start by reassuring the mother and the child and give appropriate analgesia. I may be necessary to admit
the child after discussion with my senior surgical colleague (registrar) and make sure that the child had a period
of bed rest. The gold standard procedure in this case is the fixation of the slipped upper femoral epiphysis in situ
with a cannulated screw. This prevents further slippage and encourages the physis to ossify and close. The screw
should be left in place until skeletal maturity.

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Clinical Station
Slipped Upper Femoral Epiphysis (SUFE)
Advice

Most foundation trainees are unlikely to have extensive firsthand experience of this kind of injury, given its
relative rarity. It is important to know the age group distributions for causes of hip pain in children. Remember,
paediatric surgery is a subset of core surgical training and it is possible for questions concerning adolescents to be
posed. With any questioning involving people under 18, you should emphasise the importance of good
communication with the family and reassurance of the child and the parents, who are likely to be anxious.
Analgesia is also essential. You may not be aware of the surgical management in a case such as this, but you
should have an idea of the ages affected by Perthes' disease and slipped upper femoral epiphysis.

Supplementary Information

SUFEs involve displacement of the epiphysis slipping infero-posteriorly through the growth plate. It can often
present with referred pain to the knee on the ipsilateral side.

Slips can be classified into acute or chronic, stable and unstable. Although this case does seem to have an acute
precipitant (netball), because of the interval between this occurring and the presentation, it would be classified as
chronic. As the child can weight bear, it would be categorised as stable; if the child could not weight bear, it
would be classified as unstable. In acute slips, for instance after a fall from a bike or a sporting injury in an
otherwise anatomically normal hip, efforts to reduce the femoral epiphysis and then to fix it are advisable. In
chronic slips, attempts to reduce the injury are troublesome and the risks of avascular necrosis of the femoral
head is considerable.

If untreated, SUFEs can result in avascular necrosis of the femoral head or malunion predisposing to arthritis
later in life. Symptoms may be mild, so you should have a low index of suspicion if the patient is within the
correct age group for gender.

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Clinical Station
Trauma
A 35 year old man has fallen off a bridge, he is brought into you immobilised on a spinal board, and is screaming
out in pain.

How would you manage him acutely?

I would resuscitate the patient, assessing his airway, breathing and circulation, treating any life threatening
complications, before assessing him further.

Please explain this in more detail

I would get help and ensure a trauma call has been put out and ensure that the appropriate help is on its way.

A: secure the airway and triple immobilise the cervical spine

B: look for equal bilateral chest movements, auscultate the chest, measure oxygen saturations and respiratory
rate, mention performing an ABG and arrange a portable CXR as part of a trauma series of chest and pelvis.
Start oxygen (15L, non rebreathe mask)

C: Assess haemodynamic status (heart rate, volume, blood pressure). Feel peripheries, palpate abdomen, look at
JVP, and for any bleeding source,, arrange an ECG and cannulate with two wide bore cannulae, send off bloods
including group and save and cross match and start IV fluids if hypotensive.

D: GCS – split into Eyes, Voice and Movement (see below)

Or for a more rapid assessment - AVPU:
Alert
Responsive to Voice
Responsive to Pain
Unresponsive
BM - DEFG (Don’t Ever Forget Glucose)

E: complete the primary survey whilst avoiding hypothermia

What investigations would you order?

As well as the basic bloods, including a cross match, ABG, I would like a trauma CT scan (or trauma XR series)
of this patient to assess for internal haemorrhage and injury. I would like to see an XR of their cervical spine,

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Clinical Station
Trauma
Here is his CXR, what would you do now?

This shows a right sided pneumothorax, with a fluid level, which is most likely
suggestive of haemorrhage given the history. I would reassess his ABCs, and
insert a grey cannula into the 2nd intercostal space, mid-clavicular line, to
decompress any possible tension pneumothorax,. Signs of this include
deviation of the trachea away from the pneumothorax, reduced breath sounds,
and a hyper-resonant chest to percussion on the side of the pathology. . He will
then require a chest drain. I would ask for a cardiothoracic surgical opinion to
determine the origin of the blood within the pleural cavity.

His GCS drops to 8, how would you proceed?

I would reassess him again using the ABCDE approach, paying particular attention to his airway. If one has a
GCS of 8 or below, they can no longer safely maintain their own airway, and I would ask for anaesthetic
assistance for a ‘definitive airway’ - a secured, cuffed endotracheal tube. In the meantime, I would manage his
airway with simple manoeuvres and airway adjuncts as appropriate. I would arrange a CT head, and ask for a
neurosurgical opinion if indicated.

What does the CT head show?

It shows a left sided acute subdural haematoma with midline shift. This is a
surgical emergency requiring rapid intervention by a neurosurgeon. If he were
not in a neurosurgical unit I would arrange rapid transfer of the patient at the
same time as stabilising them haemodynamically.

Advice

Throughout, whenever you ask for an investigation you will be presented with it, so make sure you can read
ECGs – likely to be normal and CXRs – may well have a pneumothorax or haemothorax. The more familiar
you are with the appearance of these the better. Know how to interpret an ABG, a pelvic Xray, and a CT head
quickly and accurately.

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Clinical Station
Trauma
People do well on this if they are quick at interpreting scans, and can make sensible decisions. It is testing your
ability to think under pressure, and your decision making, and once again, the structure of your thoughts and
answer.

Supplementary information

GCS Eyes Voice Movement

1 No response No response No response

2 Opens to pain Incomprehensible sounds Extends to pain

3 Opens to voice Inappropriate words Inappropriately flexes to pain

4 Open spontaneously Confused Withdraws to pain

5 Orientated Localises to pain

6 Obeys commands

Are you familiar with any current head injury guidelines with regards to performing a CT head scan?

The NICE guidelines for head injury assessment, investigation and early management have recently been
updated (2014) and clearly describe criteria for when to perform a CT head scan in the context of a head injury
in adults.

Criteria for CT Head scan in adults following a head injury:

If any of the risk factors listed below are present, perform a CT head scan within 1 hour:
• GCS less than 13 on initial assessment in the emergency department.
• GCS less than 15 at 2 hours after the injury on assessment in the emergency department.
• Suspected open or depressed skull fracture.
• Any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear
or nose, Battle's sign).
• Post-traumatic seizure.
• Focal neurological deficit.
• More than 1 episode of vomiting.

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Clinical Station
Trauma

For adults with any of the following risk factors who have experienced some loss of consciousness or amnesia
since the injury, perform a CT head scan within 8 hours of the head injury:
• Age 65 years or older.
• Any history of bleeding or clotting disorders.
• Dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected
from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs).
• More than 30 minutes' retrograde amnesia of events immediately before the head injury.

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Clinical Station
Hip dislocation
You are asked to assess a 58 year old gentleman on the ward who is day one post total hip replacement. They
are complaining of pain in the new hip.

How would you proceed?

When taking the call from the nurse, I would clarify the patients name, age and location. I would want to know
their observations, and what the concerns were at present. This allows me to make an initial assessment
immediately of the severity of the case, and the urgency of review.
Once I have ensured they are not acutely compromised by assessing their airway, breathing and circulation I
would take a full history, examine the patient and review the operation note, and the patient’s notes to get more
information. Specifically during examination of the hip I would assess the position, any deformity, the range of
movement and neurovascular status of the leg.

The patient had a right hip replacement operation 6 hours ago, they are now complaining of severe pain in the
right hip. On examination they are haemodynamically stable, but have a reduced range of movement and their
leg is rotated and internally rotated. What might have happened?

It is likely that they have had a dislocation of their prosthetic hip.

What would you do?

I would inform the orthopaedic registrar on call my consultant after arranging an AP and lateral hip XR and full
length femoral views, and making ensuring that they were nil by mouth, had up to date blood tests and were
otherwise haemodynamically stable. They may need to return to theatre for relocation of the joint. I would also
ensure that the patient was comfortable and had adequate analgesia.

Tell us what you do when you look at an Xray

I firstly check the demographics to ensure it is the correct patient, date,time and side. I make sure that I have two
views of the anatomy of interest, and that ideally, the joint above and the joint below are included. When
inspecting a plain radiograph in a post operative orthopaedic patient, I would look for fracture in native bone,
periprosthetic fracture, change in angulation of the prosthesis or signs of prosthetic loosening. In this case I
would then inspect the AP and lateral images to ensure that the femoral head remained within the acetabular
rim. I then would contact my registrar to report my findings.

The hip is dislocated, would you reduce it?

The hip will require reduction, however, I have no experience of this, so I would contact my registrar. I imagine

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Clinical Station
Hip dislocation
reduced. They may well require further surgical intervention, however I am unsure of this as I have little
orthopaedic experience.

Advice

This is word for word how one candidate approached this station last year. He had no orthopaedic experience
therefore felt he had struggled. The feedback he received however was positive. He scored highly for acting safely
and within my abilities and requested help early. They commented that the candidate ordered all the correct
tests, and managed the case appropriately despite obviously finding it difficult, due to a clear lack of orthopaedic
experience.

We include this here to demonstrate that while good clinical knowledge helps, you can still do well by being safe,
and logical in your management. This candidate came 26th in London last year despite feeling they had not done
well in this station.

Supplementary information

Hip replacement is an extremely common procedure with a low complication rate. However complications can
occur. Initially, the patient must be reassured and given appropriate analgesia. The hip must the be ‘reduced’ or
repositioned. This may be under light sedation if tolerated by the patient, or may be under general anaesthetic in
a formal theatre setting. Reported rates of hip dislocation after primary total joint arthroplasty varies by surgical
approach, but varies from 1 to 7% in the literature. This rate is higher in revision arthroplasty. Of those revision
arthroplasties that dislocate, a high proportion dislocate recurrently. (up to 70% reported in some studies).
Dislocation is most common in the 3 months following primary procedure and the risk declines thereafter. 45%
of dislocations are reported to occur within four weeks of the primary procedure.

Factors which increase the rate of dislocation can be divided into patient factors and surgical factors:
Patient factors include gender (female patients are almost twice a likely to suffer a dislocation than male patients),
weak hip musculature, increased age, obesity and excessive alcohol consumption. Dislocation is also more likely
in patients with neuromuscular disorders and conditions such as congenital hip dysplasia.

Surgical approach is thought to have a role in incidence of dislocation, with a higher rate using the posterior
approach, when compared with the lateral approach (However, the lateral approach is associated with a higher
rate of other post operative complication such as sciatic nerve palsy, trochanteric bursitis and increased post
operative bleeding). Capsular excision during surgery increases the risk of dislocation, as does previous hip
surgery. It has also been reported that larger femoral head sizes are associated with significantly lower risk of
dislocation.

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Clinical Station
Breakdown of an anastomosis
You are called to see a patient 69 year old gentleman on a general surgical ward. He is day 4 post open low
anterior resection with end to end anastomosis for adenocarcinoma of the proximal rectum. He complains of an
8 hour history of severe abdominal pain, which has spread from the periumbilical region to his entire abdomen.
He has a blood pressure of 100/68, with a pulse rate of 128bpm and a temperature of 38.1 degrees. On
examination, his abdomen is rigid and tender, with diffuse guarding and rebound tenderness on palpation.

What would you do initially for this patient?

I would assess the patient’s airway, breathing and circulation. Given that the patient is showing signs of
haemodynamic instability, I would start with fluid resuscitation of the patient with intravenous fluids, whilst
continuing blood pressure monitoring. I would start appropriate intravenous analgesia using the WHO pain
ladder. I would take a full set of bloods from the patient, including full blood count, CRP, U&Es (to check for
electrolyte imbalance) group & save, venous blood gas. I would contact the registrar on call to alert them to the
case, as well as to the possibility of this patient requiring surgical intervention. I would make the patient nil by
mouth and order an emergency abdominal CT scan. I would also contact microbiology and start broad spectrum
intravenous antibiotics after taking blood cultures. I would contact the on-call anaesthetist and alert the
emergency theatre team as I would anticipate the need for an emergency surgical procedure to manage this
patient.

What would be your differential diagnosis in this case and why?

My leading differential diagnosis would be anastomotic leak with resultant faecal peritonitis. I would also
consider a post operative abscess, which could classically present with a ‘swinging pyrexia’ with or without a
palpable mass. However, anastomotic leak would be my main differential because of the high leak rate of low
rectal anastomosis when compared with intraperitoneal colonic anastomoses. This presentation has many
features of the classic presentation of anastomotic leak; rigid, peritonitic abdomen, severe abdominal pain,
tachycardia, fever and haemodynamic instability. Localised abscess could be associated with pain and fever, but
would not tend to cause the diffuse, rigid peritonism described in this case

Do anastomotic leaks always present in this way?

No. A proportion present more insidiously, with a post operative failure to thrive, extended period of ileus or mild
pyrexia. These are the patients in whom a leak may be difficult to differentiate from an abscess.

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Clinical Station
Breakdown of an anastomosis

What are the risk factors for anastomotic leak?

Risk factors can be grouped into patient related factors and operative factors.

Patient related factors include age and gender (males and older patients are more likely to suffer anastomotic
leaks), malnutrition, long term steroid treatment, obesity, tobacco and alcohol use, leucocytosis, diverticulitis and
cardiovascular disease.

Operative factors include sepsis, operative time greater than two hours, perioperative blood transfusion, (which
could be associated with an element of perioperative bowel ischaemia) and the level of the anastomosis. (Low
rectal anastomoses are significantly more likely to leak than intraperitoneal colonic ones.
Surgical error is the final operative risk factor. Inappropriate formation of primary anastomosis, in cases where
faecal diversion in the first instance would have been more appropriate, can lead to increased incidence of leaks.
In addition, poor surgical technique at the formation of the anastomosis are associated with higher rates of
breakdown.

Are there any alternative to CT scanning in the investigation of anastomotic leak?

CT scanning is the gold standard test for the investigation of anastomotic leak. Contrast enema can have a role
in identifying leaks in combination with CT scans, but is not used independently as standard.

How would this case be surgically managed?

This case would likely be managed by extensive washout and drainage with proximal faecal diversion with either
a colostomy or an ileostomy.

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Clinical Station
Breakdown of an anastomosis
Supplementary Information

There is a reported complication rate of up to 18% for low anastomoses such as a low anterior resection. One
third of post operative deaths after colorectal surgery are associated with anastomotic leak and mortality rates of
7.5 to 36% is reported in the literature. This is increased to a reported mortality rate of up to 50% in cases of
low rectal anastomosis during anterior resection. There is no common diagnosis for anastomotic leak. One
retrospective study into recent reviews found 56 separate definitions of anastomotic leak. It may be defined
clinically, or by the need for a re-operation or on a radiological basis. It is well recognised clinically, and is
characterised by peritonitis, purulent or faecal discharge from the wound site or drain and the presence of
absence or fever. The consequences of leak can range from intra-abdominal abscess, enterocutaneous fistula and
diffuse peritonitis. Anastomotic leak is associated with increased local recurrence and reduced survival rates after
large bowel resection for colorectal carcinoma. Surgical options for the management of anastomotic leak include
faecal diversion with a loop ileostomy or colostomy (as the candidate recommended in this scenario), or resection
of the anastomosis with a ‘sewing up’ of the proximal stump (Hartmann’s procedure). Faecal diversion allows the
possibility of future restoration of a patent anastomosis, but is only an option when dealing with patent bowel. In
cases of frank faecal peritonitis such as this, the chances of being able to form a satisfactory anastomosis at a
future date is significantly reduced. In cases of anastomotic leak involving intra-abdominal anastomosis, the
Hartmann’s procedure is most effective at controlling the leak, but has the downside of numerous difficulties in
restoring bowel continuity at a later date.

Advice

This is an extremely common question in surgical interviews. It tests a basic level of surgical knowledge and
understanding of abdominal surgery. This answer is strong as it gives sufficient detail, whilst still answering the
question fairly succinctly. Whenever you are asked a question about risk factors, a good candidate will always try
to structure their answers rather than just reciting a list. This can be into pre-operative, operative and post
operative; patient related and surgery related or another method that you may use yourself, but it can act as a
useful memory aid and will let the examiner know that you are a structured and logical thinker. Your answer
should make it clear that you recognise the significant increase in post operative mortality related to the diagnosis
and you should mention contacting your seniors and preparing the patient for theatre at an early stage. Also, stick
to your guns. If you know that CT scanning is the gold standard method of radiological investigation, then say
it. Don’t doubt yourself because of a question such as the one in this case.

You will notice the last answer on surgical management is brief. The panel do not expect you to have an in depth
knowledge of surgical technique at this time, but this answer is succinct and shows an understanding of the need
for bowel rest of the distal colonic segment, as well as the anatomy of the colon.

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Clinical Station
Abdominal pain
You are the surgical SHO on call. You are referred a 35 year old gentleman complaining of severe and
unremitting peri-umbilical pain, which started very suddenly whilst at work around 4 hours previously. He
assesses the severity as 10/10. He has felt well recently and has no history of fever, nausea, vomiting, night sweats
or change in bowel habit.

He occasionally suffers from ‘heartburn’, but this is relieved by a glass of milk before bed. He has not seen his GP
for this problem. On this occasion, a glass of milk and an antacid have not given any symptom relief. He smokes
15 cigarettes/day and consumes 10-12 pints of beer per week.

His observations are as follows: BP: 120/75 P: 115 T: 37.9 deg

What are your differential diagnoses?

Peptic ulcer disease would be my leading differential diagnosis due to his gender, smoking and alcohol history. His
previous symptoms are suggestive of gastric reflux could indicate acid hypersecretion, which would increase his
risk of peptic ulcer formation.
The acute onset of severe central abdominal pain suggests that this patient may have a perforated viscus,
secondary to peptic ulcer disease.

I would of course consider other common causes of abdominal pain in this age group such as appendicitis,
cholecystitis, nephrolithiasis, genitourinary infection or testicular torsion.

How would you proceed with this patient?

I would ensure that the patient was stable, assessing him according to the ALS ABC principles and take a history
from the patient. I would complete a full examination, focussing on the abdominal examination. Bedside tests
would include an ECG (to exclude a cardiac origin for the pain, especially with a known history of ‘heartburn’
pain), basic observations and urinalysis.

I would order blood tests including a full blood count, urea & electrolytes, liver function tests and C-Reactive
Protein. I would order an erect chest xray to exclude a perforated viscus and a plain abdominal film to look for
radiological signs of abdominal obstruction. I would take an arterial blood gas to look for a raised lactate and
consider further imaging such as a FAST (Focussed Abdominal Sonography in Trauma) scan or a CT abdomen
depending on the results of other investigations.

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Clinical Station
Abdominal pain
Explain your rationale for carrying out these investigations?

ABG Lactate – important marker of infection, particularly intraabdominal sepsis, as well as

tissue ischaemia
FBC Low Hb from a subacute or chronic GI bleed
Raised WBC in infection
U&Es Indication of renal obstruction
For baseline – especially if considering using contrast for CT
CRP Marker of inflammation/infection

LFTs Indication of biliary obstruction (raised alkaline phosphatase)

Acute hepatitis – raised ALT
Clotting Sepsis can cause deranged clotting

G&S In preparation if patient needs to go to theatre

Urinalysis Blood – UTI/nephrolithiasis
WBC – UTI/nephrolithiasis/pyelonephritis
(You are more likely to be asked about one or two tests but for the purpose of revision this table is useful)

What would you do if the patient was unable to sit up straight for the erect chest X-ray?

I would always try to get an erect CXR as it is a rapid way to visualise free air on plain film. However, if this was
not possible, a left lateral decubitus film (left side down) could be used to demonstrate free air between the liver
and lateral abdominal wall.

Your examination reveals a diffusely tense abdomen with guarding in the epigastrium. There is no renal angle
tenderness. Your x-ray has appeared on PACS.

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Clinical Station
Abdominal pain
What does the X-ray show?

This is an erect chest radiograph, in with the patient is partially

rotated. Free air is seen between the right hemi-diaphragm and
the liver. This image, in combination with the associated history
and presentation, would make a diagnosis of perforated peptic
ulcer most likely.

How would you proceed to manage this patient?

I would ask the on-call surgical registrar to review the patient as a matter of urgency, highlighting my concerns
regarding the likely diagnosis of perforated peptic ulcer and the current condition of the patient. I would put
high flow oxygen in place. I would ensure that the patient had two wide bore cannulae in situ. I would start
intravenous analgesia, based on the WHO pain ladder, starting with IV paracetamol, (in the absence of allergy).
I would start IV fluid resuscitation therapy, titrated to blood pressure, with a 500ml gelofusine fluid challenge if
the patient was clinically shocked followed by 4-6 hourly ‘normal’ saline or Hartmann’s solution if there was
satisfactory response to this challenge. I would insert a nasogastric tube to decompress the stomach and a foley
catheter to enable measurement of urine output.

I would take blood cultures before commencing broad spectrum antibiotics according to local protocol for intra
abdominal sepsis. In some cases, a central line could be necessary to assess intravascular fluid status. I would
discuss this with the surgical registrar on call. Aware that the patient could require surgical intervention, I would
make the patient ‘nil by mouth’ and ensure that a group and save blood test had been sent. After discussion with
a senior colleague, I would also discuss the patient with the anaesthetic registrar and theatre staff to alert them to
a possible impending emergency laparotomy. Should my senior think this was necessary, I would consent the
patient for the procedure (or provide the paperwork for the registrar) to ensure no delay to the operation.

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Clinical Station
Abdominal pain
Which features determine operative mortality?

Operative mortality in a patient with peptic perforation depends on four major risk factors:

• Length of time from perforation to admission

• Age
• Medical co-morbidity
• Hypovolaemia on admission

Do you know of any national or international guidelines for the management of sepsis?

The surviving sepsis campaign is a programme introduced by the European Society of Intensive Care
Medicine, aiming to increase awareness, understanding and knowledge surrounding the treatment of sepsis. Its
overarching aim is to reduce the mortality associated with sepsis by 25% (from 2009). The premise is that this can
be achieved by early recognition of septic patients, more targeted allocation of resources and setting clear goals.

These include:

• Time from A&E admission to presumptive diagnosis of severe sepsis <2 hours
• Time from A&E admission a presumptive diagnosis of severe sepsis having a lactate blood test < 4 hours
• Time from A&E admission to appropriate antibiotics less than 4 hours
• Blood cultures taken before the administration of antibiotics - to increase the likelihood of identifying an
organism and therefore appropriately targeting antibiotic prescription.
• If hypotensive or if lactate greater than 4.0mmol, immediate fluid resuscitation is started (at least 30 mL/kg
normal saline or Hartmann’s solution within one hour)

Supplementary information

Some authors have suggested that in patients with perforation, but without radiological evidence of
pneumoperitoneum, conservative management is indicated as the perforation can be assumed to have ‘sealed off ’
independently. The majority of centres advocate surgical management in cases with both peritonism and
pneumoperitoneum.

Despite strong arguments favouring nonoperative treatment of patients with perforated PUD without free air,
delaying the initiation of surgery more than 12 hours after presentation has been demonstrated to worsen
outcome. Therefore, when indicated, a laparotomy should be performed as soon as possible. The choice of
operative procedure would depend on variables such as the presence of hypovolaemic or septic shock, the degree
of peritonitis and evidence or history of chronic peptic ulceration. Laparoscopic procedures have been more

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Clinical Station
Abdominal pain
recently described. However, in the presence of significant co-morbidity or severe intra-abdominal sepsis, the
classical management is repair of the perforation with an omental (Graham) patch via upper midline laparotomy.

In patients with a prior ulcer history and without significant co-morbidity or systemic upset, a definitive ‘anti-
ulcer’ operation could be indicated to reduce recurrence rates. For a perforated duodenal ulcer (DU), this could
include a highly selective (parietal cell) vagotomy, truncal vagotomy with pyloroplasty or vagotomy with
antrectomy. In a stable patient, the ulcer would be excised and sent for frozen section analysis to exclude
malignancy.

For a benign gastric ulcer, a distal gastrectomy with either a Billroth I gastroduodenostomy or a Billroth II
gastroduodenostomy would be most appropriate. This would carry significant morbidity and not be indicated in
the acute setting.

Recurrence Rates
Any procedure that preserves vagal innervation or antral gastrin production can lead to recurrence. Recurrence
rates for various operative techniques are as follows:

• Highly selective vagotomy: 5-20 %

• Vagotomy with pyloroplasty 10-15%
• Vagotomy with antrectomy <2%

Definition of sepsis
(www.survivingsepsis.org)
Documented or suspected infection with one or more of the following:

hypothermia/pyrexia core temperature <36degrees/>38.3 degrees

increased heart rate >90bpm

tachyopnoea

altered mental status

oedema or positive fluid balance >20ml/kg over 24hrs

hyperglycaemia in the absence of diabetes plasma glucose >120mg/dl

leucocytosis or leucopenia WBC >12,000/uL or <4,000/uL

raised CRP

raised procalcitonin

increased O2 requirement SvO2 >70%

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Clinical Station
Projectile vomiting
You are the paediatric surgical SHO on call. You are called by A&E to see a 6 week-old boy who according to his
mother, has been suffering from projectile vomiting following feeds for the last 3 days.

What would be your main differential diagnosis in this child?

This history would be consistent with a diagnosis of (infantile hypertrophic) pyloric stenosis, most common in
boys around one month of age. This boy is younger than the classic age group (6-18 months) for intussusception,
(which would classically present with ‘redcurrant jelly stool and abdominal pain). Viral gastroenteritis would be
the most common cause of generalised GI complaint in the whole paediatric population, but I would want to
exclude more serious pathologies before making this diagnosis.

What are the most important pieces of information to gather from your history and examination?

Given the history of vomiting for three days, the most important factor to assess would be the infant’s hydration
status. I would take the child’s blood pressure and observations, and look at his tongue, mucous membranes and
fontanelles. I would ask about whether the number of wet nappies had changed. I would assess his weight and
plot this on his growth chart. Weight loss would be an indicator of nutrition/hydration status.

I would also look at the child in general; a quiet, floppy baby suggests illness or dehydration. I would ask the
mother about the colour of the vomitus. Pyloric stenosis is classically associated with non-billous vomiting, as the
obstruction is proximal to the pancreatic duct. The child would classically be hungry and feed eagerly
immediately after vomiting. I would also ask about other GI symptoms such as diarrhoea and systemic features,
such as fever and lethargy. I would ask about belching, and crying (indicating abdominal pain), both of which
could accompany pyloric stenosis. I would ask about any previous similar episodes and his growth and
development history to date. A family history of similar problems may be uncovered.

On examination, I would feel for the abnormal pylorus, which may feel like an olive-shaped mass. I would
inspect the abdomen for visible peristalsis during feeding and just prior to vomiting episodes. The abdomen may
be generally distended.

His observations are as follows:

Temp: 36.5 deg HR: 120 BP: 75/50 RR: 24 weight 6.1 kg

The child is resting in his mother’s arms, occasionally crying. He has sunken fontanelles with dry mucous
membranes. His abdomen is soft and non tender with a mobile, olive shaped mass in the epigastric region.

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Clinical Station
Projectile vomiting
Would this change your diagnosis and what would you do next?

Whilst diagnosis of infantile pyloric stenosis is primarily from history and examination, the finding of an ‘olive
mass’ is close to being ‘pathognomonic’ for the condition, but is often difficult to elicit clinically. It would
reinforce my previous impression.
Importantly this child appears dehydrated. They require fluid resuscitation and senior paediatric input. I would
order a ‘standard’ set of bloods including FBC, U&E and LFT and a venous blood gas. I would contact the
paediatric surgical registrar on call. I would order an abdominal ultrasound scan (USS) to examine the width and
length of the abnormal pylorus. A less commonly used form of imaging option would be an upper GI series
(after giving the child an oral contrast agent).

What would you expect your venous blood gas result to show and how would you explain this result?

The electrolyte picture most commonly seen in a vomiting patient would be a hypochloraemic hypokalaemic
metabolic alkalosis (with paradoxical aciduria). The hypochloraemia is caused by the loss of hydrochloric acid in
vomitus from the stomach. This causes the patient to become alkalotic. To compensate for this, hydrogen ions are
moved from the intracellular to the extracellular space in exchange for potassium ions. In addition, the kidneys
upregulate the renin-angiotension aldosterone system, retaining sodium ions and secreting potassium ions. This
causes a net reduction in the extracellular pool of potassium ions, causing hypokalaemia. With the progression of
hypokalaemia and hypovolaemia, the kidneys continue to exchange hydrogen ions for sodium. This explains the
increasing alkalosis and paradoxical aciduria. Dehydration can lead to hyper- or hyponatraemia.

What is the classic finding on abdominal USS in pyloric stenosis?

An USS would show a thickened pylorus. (A thickness of greater than 3mm would suggest the diagnosis).
Other USS findings can include:
Target Sign: Hypoechoic ring of hypertrophied pyloric muscle around echogenic mucosa centrally on cross
section.
‘Antral nipple sign’: Pyloric mucosa protruding into gastric antrum.
‘Cervix sign’: Indentation of muscle mass on fluid-filled antrum on longitudinal section.

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Clinical Station
Projectile vomiting
What does the image below show?

This image shows the ‘string sign’ during an upper GI series, which
represents the passage of small barium streak through the stenosed pyloric
channel. It supports a diagnosis of pyloric stenosis.

How would you manage this patient?

Having contacted senior help (paediatric surgical registrar on-call & the
paediatric accident and emergency team), my initial management would
follow the paediatric advanced life support guidelines for hypovolaemic
shock/dehydration.

I would correct the fluid deficit and acid/base imbalance. If the patient showed signs of clinical dehydration
(sunken eyes, reduced skin turgor, lethargy, pallor, dry mucous membranes, sunken fontanelles), I would obtain
IV/IO access and then give a 20ml/kg bolus of crystalloid fluid. I would ensure that a group and save was taken
and discuss the patient with the paediatric theatres and anaesthetist on call. I would continue to reassess the
child’s fluid balance and a nasogastric tube would be indicated in some cases.

What are the options for definitive management and what are their benefits?

Infantile pyloric stenosis is a surgical emergency. The definitive management is corrective surgery. The Ramstedt
pyloromyotomy is the classical procedure of choice. This was traditional performed through a right upper
quadrant transverse incision, but recent studies have shown comparable results with circumbilical incision (better
aesthetic result) and laparoscopic pyloromyotomy (shorter in-patient stay)

Supplementary Information:

Infantile hypertrophic pyloric stenosis is not truly a congenital disorder. It affects the circular muscle of the
pylorus causing it to elongate and thicken. (see below)

The incidence is 2.4 per 1000 live births in Caucasians, 1.8 in Hispanics, 0.7 in Blacks, and 0.6 in Asians The
cause of this condition is not fully understood. It affects 3-5/1000 live births and affects boys: girls in a 4:1 ratio.
It is most common in first born sons and has a strong genetic component with a 20% risk of a son being affected
if a mother was affected, a 7% risk if a mother was affected, a 5% risk of a son being affected if a father was
affected and a 2% risk to a son if the father was affected. Feeding can be restarted within 12-24 hours of surgery
and recurrence and post operative complications or mortality are rare.

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Clinical Station
Difficulty urinating
You are the urological SHO on call in a District General Hospital. You are called by the FY2 in A&E who refers
a 70 year old black gentleman with a 2 month history of progressive difficulty initiating urination and 7kg of
weight loss over the same period. He has no other urinary symptoms and denies other medical history

What is your differential diagnosis and what further features would you want to fully investigate in your
history?

In a male patient of this age, my primary differential would be of bladder outlet obstruction, most likely due to
prostatic enlargement of a benign or malignant cause. I would consider structural causes, including urethral
stricture, chronic prostatitis, bladder neck stenosis and chronic faecal impaction. I would look to exclude
functional problems, such as bladder neck dysynergia and neurological disease including MS and diabetic
autonomic neuropathy.

I would ask about family history of prostate cancer or benign prostatic hypertrophy, about his dietary fat intake,
and whether he had any systemic symptoms of malignancy such as loss of appetite and smoking history, bony
pain or an occupational history of cadmium exposure (found in cigarettes, batteries and those working in the
welding industry).

How would you assess the patient and what diagnostic tests would you perform?

I would perform a full physical examination, feeling for a palpable bladder, abdominal masses, prominence of
inguinal lymph nodes or other groin lesions. I would perform a digital rectal examination, feeling for nodules or
changes in the texture or asymmetry of the prostate. I would feel for long bone, spinal and pelvic bony tenderness
and perform a full neurological examination, including assessment of external anal sphincter tone on PR
examination to exclude gross signs of spinal cord compression.

I would perform urinalysis, to exclude urinary tract infection and identify haematuria, and take blood tests for
serum urea and creatinine, PSA and liver function tests including alkaline phosphatase. I would ask for
assessment of post-void residual urine volume. I would contact the urology registrar on call, with the results of
my examinations and investigations. If there was evidence of bladder distention, I would place a foley catheter to
relieve the obstruction in the absence of contraindications.

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Clinical Station
Difficulty urinating
On examination, you find left leg swelling, with prominence of the inguinal lymph nodes. His PSA result is
elevated. On PR examination, you find normal tone and an indurated, symmetrically moderately enlarged
prostate with no other masses. What is the definitive investigation?

The gold standard is needle prostate biopsy, under transrectal ultrasonography guidance, in cases of suspected
prostate malignancy. This allows staging of the disease using the Gleason score if malignancy was confirmed.

The biopsy reveals a prostate cancer, which is assigned a Gleason score of 6 (3+3). Which investigations would
you recommend and why?

I would arrange chest radiography, full blood count and clotting, as well as an ECG and group and save if the
patient was to be managed surgically. MRI is helpful for localising cancer within the prostate and seminal vessels
for local staging. CT or MRI are used to identify metastatic deposits. Prostate cancer most commonly
metastasises to the bone, and less commonly the lungs, liver and pleura. PET scanning can also help to identify
these deposits.

What is the relevance of the Gleason score?

Prostate cancer is a very common malignancy and the Gleason score is the major scoring system used at present.

The Gleason grading system is used to determine prognosis in patients with prostate cancer based on the
histological evaluation of tumour biopsy specimens. It is a measure of the normality of the normal glandular
structure of the epithelium. A grade of 1 indicates a normal or near normal pattern, with a grade 5 scoring
indicating the absence of any recognisable glandular pattern. The predominant and second most predominant
pattern are graded and the sum of these two grades comprises the Gleason score.

Gleason Score

2-4 Low grade or well differentiated tumour

5-7 Moderate-grade or moderately differentiated tumour

8-10 High grade or poorly differentiated tumour

Patients with a Gleason score of 4 or lower tend to do well clinically, whilst those with a Gleason score of 6 or
higher are likely to have, or to progress to a diagnosis of advanced or invasive cancer.

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Clinical Station
Difficulty urinating
Models have recently been developed that combine the clinical stage (determined by PR findings), Gleason score
and the PSA level in an attempt to predict the likelihood of local extension, as well as the time to development of
clinically metastatic disease.

What are the treatment options for prostate cancer?

In many cases, treatment may not be indicated. This could be due to the character of the tumour itself (low
grade, indolent) or due to the co-morbidity or frailty of a patient in cases where surgical management would
otherwise have been indicated.

Standard treatments for clinically localised prostate cancer include radical prostatectomy, radiation therapy
(including brachytherapy and external beam radiation), hormonal therapy, a combination of the above or active
surveillance, (careful observation of the tumour over time, with the intention of treatment for cure if there are
signs of cancer progression). For the 50-75% of patients with prostate cancer that will cause no harm before the
man dies from an unrelated pathology or old age, active surveillance may be indicated.

Hormonal therapy and radiotherapy are reserved for extra-prostatic spread in many cases. However, radiation
therapy may be used for some advanced tumours and hormonal therapy can be used for some early tumours.

Supplementary Information

Prostate cancer is the most common non-cutaneous cancer amongst

males and the second most common cause of cancer death in males. It
is an adenocarcinoma or glandular cancer that is caused by mutations
in the normal semen producing prostate gland cells, most commonly in
the peripheral zone.

There is marked variance in incidence with geography. Highest rates

are found in North America, Australia, Northern and central Europe,
with the lowest rates in South-eastern and South central Asia and
Northern Africa. 47% of cancers are identified in asymptomatic
patients.

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Clinical Station
Difficulty urinating
Gleason Grade 4 and 5 cancers are associated with adverse pathological findings and disease progression. Low
grade tumours can also be biologically aggressive, though in the main, they do tend to be associated with better
overall outcomes.

The ranges for disease free 10-year survival for early localised disease are as follows:

Treatment Disease free 10yr survival

Radical prostatectomy 80-95%

Brachytherapy and external radiation 80-95%

Watchful waiting’ 50-73%

Genetic background may contribute to the risk of developing prostate cancer. Men with a 1st degree relative
(father or brother) with prostate cancer have twice the risk of developing prostate cancer and those with 2 first
degree relatives affected have a 5-fold greater risk compared with men with no family history. Whilst no single
gene has been identified as causative, mutations in the BRCA1 and BRCA2 genes, more commonly associated
with breast and ovarian cancer, are two of the genes that have been found to be associated with prostate cancer.

Prostate cancer, especially the most common low grade forms found in the typical male elderly patient often is
indolent requires no treatment.

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Clinical Station
A painful leg
You are the orthopaedic surgical SHO at a District General Hospital. You are called to see a 32 year old
gentleman who sustained a closed fracture of the left tibia and fibula in a motorcycle accident ten hours
previously. His fracture has been reduced and put in a cast. However, he now complains of throbbing left foot
pain and numbness.

What would be your differential diagnoses?

My chief concern is the development of acute compartment syndrome. Other differentials include acute limb
ischaemia or a deep vein thrombosis, although this presentation would not fit with the usual time course for a
DVT.

You suspect that the patient has compartment syndrome. What are your initial actions?

Acute compartment syndrome is a limb threatening surgical emergency. I would immediately remove the lower
limb plaster cast and discuss the patient with the orthopaedic surgical registrar on call. I would examine the limb,
inspecting for pallor and skin changes, feeling the temperature of the limb, palpating for distal arterial pulses
(dorsalis paedis and anterior tibial) as well as determining capillary refill time, and assessing sensation in the limb.
I would ask the patient to plantarflex and dorsiflex the toes and ankle and document the range of movement, and
pain on movement. I would also assess pain on passive movement.
If I could not palpate distal pulses, I may consider the use of a handheld doppler.

If the patient was unconscious, I would measure pressure in each of the four lower limb compartments with an
electronic arterial pressure monitor if one was available.

Distal pulses are intact and easily palpable. The

skin is pink, but does look slightly ‘shiny’. He is
not able to extend his great toe and has a loss of
sensation in his 1st web space. His anterior
compartment pressures are 38mmHg. Pressures
in the other 3 compartments are < 18mmHg. His
symptoms have not improved with cast removal.
How would you proceed?

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Clinical Station
A painful leg
This patient would need a compartmental decompression by fasciotomy. I would alert the anaesthetic registrar on
call, as well as theatre staff. I would elevate the limb to the level of the heart and give intravenous analgesia as per
the WHO pain ladder and starting with IV paracetamol. I would insert two wide bore cannulae intravenous line
and send bloods (including group and save) and consent the patient for a fasciotomy. I wound ensure sufficient
IV hydration to maintain an adequate urine output in case of rhabdomyolysis.

What compartment do you think is affected and why?

The loss of great toe extension and sensation in the 1st webspace would indicate involvement of the deep
peroneal nerve. This runs in the anterior compartment.

At what compartment pressure is it considered to be ‘elevated’?

Compartment syndrome is a clinical diagnosis. Various recommendations of compartment pressure thresholds

have been used. Generally, a compartment pressure is considered elevated if it is more than 30 mmHg or when it
is within 35 or 40 mmHg of the patients diastolic blood pressure. However, these numbers are not a hard and fast

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Clinical Station
A painful leg
What are the ‘classical’ symptoms of compartment syndrome?

The ‘6 Ps’ classically associated with compartment syndrome are:

• Pain (out of proportion to what would be expected)
• Paraesthesia (may be in the cutaneous distribution of a nerve in the affected compartment)
• Pallor/pale
• Pulselessness
• Pressure
• Paralysis (late finding)

Of these, only the first two (pain and paraesthesia) are reliably diagnostic. Pain is almost universal and commonly
described as severe, deep, constant and poorly localised. Pulses are frequently retained, as the pressures that result
in compartment syndrome are not usually sufficient to occlude the arterial ‘inflow’ pressure.

Supplementary Information

Compartment syndrome is defined as the compression of nerves, blood vessels and muscle inside a closed space
(compartment) within the body. Deep fascia envelops the limbs and other fascial planes divide the limbs into
compartments. The forearm has two compartments, the thigh has three compartments and the lower leg has four
compartments (see above). Compartment syndrome can affect compartment of the forearm, lower limb, upper
arm, abdomen and buttock, but the forearm and lower leg are most commonly affected.

Two distinct types of compartment syndrome have been recognised. The first type is associated with trauma to
the affected compartment, as seen in open/closed fractures or muscle injuries. The second form, called exertional
compartment syndrome, is associated with repetitive loading or microtrauma related to physical activity. Thus,
compartment syndrome may be acute or chronic in nature.

Pressure increase within a confined space causes tissue necrosis, nerve injury and muscle infarct within 6-10 hours
from a lack of microvascular inflow within compressed tissues. Pressure-induced functional deficits are likely
caused by decreased tissue perfusion rather than a direct mechanical effect. Therefore, the amount of pressure a
limb can tolerate depends on limb elevation, blood pressure, haemorrhage, and arterial occlusion. In addition to
local morbidity caused by muscle necrosis and tissue ischaemia, cellular destruction and alterations in muscle cell
membranes lead to the release of myoglobin into the circulation. This circulating myoglobin results in renal
injury. Advanced compartment syndrome may result in rhabdomyolysis, and conversely, rhabdomyolysis may
result in compartment syndrome. Mortality is usually due to renal failure or sepsis from difficult wound
management, hence the importance of adequate intravenous hydration as soon as the diagnosis is suspected.

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Clinical Station
A neck lump
You are the ENT SHO asked to review a 40 year old lady who has presented to A&E with a neck mass. She
complains of a 2 month history of ‘tightness’ in her neck.

She denies pain or breathlessness, but feels that over the previous fortnight, she can feel a more palpable mass on
the front of her neck.

What questions would aid your differential diagnosis and how would you examine her?

A neck masses is a common presenting complaint. The most common causes are masses of the thyroid or
parathyroid, neoplastic origin (primary or secondary) or an infectious cause such as an abscess or infectious
lymphadenopathy. The differential diagnosis can vary considerably based on patient demographics and the
location of the mass. Specific questions from the history include; symptoms of thyroid disease such as
temperature intolerance, lethargy and unintentional weight gain or weight loss. Risk factors for malignancy
include; radiation exposure, iodide deficiency, smoking, alcohol use and unintentional weight loss. I would ask
about symptoms of systemic upset, such as fever and nausea, which could be a sign of an infectious cause. I
would also ask about a family history or personal of other endocrine disorders, which would increase my
suspicion of thyroid or parathyroid cause.

After reviewing baseline observations and ensuring the patient was stable, I would fully examine the lump. This
would include; checking for attachment to underlying structures, pain on palpation and movement of the lump
on extrusion of the tongue and on swallowing. I would examine the edges of the mass for regularity and
symmetry and look for other systemic manifestations of thyroid disease, such as eye signs (exophthalmos and lid
lag), tremor and pre- tibial myxoedema.

The patient reports no PMH, FH or DH. She has felt lethargic and tired over the past 6 weeks and has had
7lbs of unintentional weight gain.

Your examination is as follows:

Temp: 36.8 deg BP: 115/70 HR: 85 No exophthalmos or other thyroid eye signs.
4 x8 cm firm, painless irregular mass in the anterior midline. It moves with swallowing. No dominant nodules
with no other cervical masses, no cervical, abdominal or inguinal lymphadenopathy. No myxoedema. NS: Mildly
globally hyporeflexic.

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Clinical Station
A neck lump
What would be your next step?

The history and examination correlate with diffuse thyroid enlargement. This case would need to be discussed
with the ENT registrar on call, as well as the endocrinology registrar on call. Liaison between the medical and
surgical team in this case would be essential for optimal management.

I would take thyroid function blood tests, including serum thyroxine (T4), triiodothyronine (T3) and thyroid
stimulating hormone (TSH) levels and would check calcium and parathyroid hormone (PTH) levels to exclude
parathyroid involvement.

This patient is found to have elevated TSH and a depressed T4 level. Additional blood tests are sent and she
tests positive for antithyroglobulin antibodies and antimicrosomal antibodies. What is the most likely diagnosis?

The elevated TSH, depressed T4 and presence of specific antibodies leads to a diagnosis of Hashimoto’s
thyroiditis. However other causes of hypothyroidism should not be immediately excluded.
AMAs are 99% positive in Hashimoto’s, 80% in graves, but the latter is associated with increased T4.
Hashimoto’s is the most common cause of hypothyroidism in UK and US. Weight gain, plus lethargy plus
antibody results would make this the most likely diagnosis

How would you investigate this mass?

This patient required triple assessment with a history/examination, ultrasound imaging and a fine needle
aspiration for histology.

FNA shows diffuse parenchymal infiltration by lymphocytes and metaplasia of the normal cuboidal cells. No
malignant cells are identified. Is there a role for surgical management of this lump at this stage?

If the FNA excluded the presence of malignant cells, there would be no indication for surgery at this time, so
long as there is no local compression of the trachea, oesophagus or superior vena cava. Surgery would be
indicated if there was evidence of malignancy, radiological or symptomatic evidence of tracheal deviation or
compression, continued growth of the goitre despite hormonal therapy or according to patient request due to
significant cosmetic deformity.

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Clinical Station
A neck lump
What is your management plan?

This condition is commonly associated with underlying hypothyroidism and bouts of hyperthyroidism. This
patient would be managed primarily by the endocrinology team in the absence of an indication for surgery, with
levothyroxine (thyroid replacement therapy) and regular assessment of thyroid hormone status.

Supplementary Information

Imaging in thyroid pathology:

Historically, radionuclide scanning was the mainstay of assessment. Nuclear imaging could be used to describe a
nodule as hot (autonomously functioning), warm (normal thyroid function) or cold (hypo- or non-functioning
thyroid function). 5-8% of warm and cold nodules are found to be malignant on FNA.

Ultrasonography is now more commonly used to determine the shape and size of an enlarged gland. However,
by itself, it is not able to differentiate between benign and malignant disease. US-guided FNAB may be preferable
to palpation-guided FNAB and image-guided FNAB may be particularly helpful in the assessment of
nonpalpable or small nodules.

CT or MRI scanning is generally not cost-effective in the initial evaluation of solitary thyroid nodules. Such
studies may be useful in the assessment of thyroid masses that are largely substernal. FNAB is highly accurate,
with mean sensitivity higher than 80% and mean specificity higher than 90%. The accuracy of FNAB in
diagnosing thyroid conditions depends on the cytopathologist's expertise and experience and the technical skill of
the physician performing the biopsy. FNAB is cost-effective compared with traditional workups that heavily
depended on nuclear imaging and ultrasonography. Routine use of FNAB in the evaluation of thyroid nodules
can reduce the need for diagnostic thyroidectomy by 20-50% while increasing the yield of cancer diagnoses in
thyroid specimens by 15-45%

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Clinical Station
Shin pain
You are the orthopaedic SHO. You are asked to review a 14 year old boy who complains of a dull, but constant
pain in his left shin that has been worsening over the past 4 days. 10 days ago, he fell, scraping his left knee whilst
playing football in a field near his house, but the wound has now healed. He presents with his parents. He is
otherwise fit and well.

What is your differential diagnosis?

I would want to exclude a fracture, given the history of trauma and pain. The association with fever and recent
trauma could be suggestive of an infectious process such as an infected haematoma or bursitis. I would also
consider a primary bony malignancy with associated inflammation.

How would you initially manage and investigate this patient?

I would start with a full set of observations (including BP, HR and temperature), as well as a history (weight loss
and other systemic symptoms) and examination of the painless and then the painful limb. I would also complete
a general examination, including abdominal palpation to look for occult masses, and the cervical, abdominal and
inguinal region for lymphadenopathy.

I would give appropriate analgesia as per the WHO pain ladder, using the paediatric BNF for assistance on
dosing. I would take bloods, including a full blood count (FBC), an ESR, liver function tests (LFTs), especially
alkaline phosphatase, and blood cultures, if i suspected an infectious cause for the pain. I would order a plain film
of the affected limb, including AP and lateral views of the proximal and distal joint. I would particularly inspect
these films for evidence of metaphyseal bony destruction (cortical lucency) and periosteal reaction. However,
there is potential for radiological features to lag being the clinical presentation).

On examination

Observations: Temp 35.5 degrees HR: 79 BP: 124/75

Abdominal examination unremarkable, no hepatosplenomegaly. Right lower extremity unremarkable with good
ROM.
Left antero-lateral shin with 4 x 5 cm area of erythema and tenderness; no fluctuance or underlying mass, no
inguinal lymphadenopathy. Left knee: slight swelling, no erythema, non tender, full ROM.
Bloods: elevated ESR, slightly elevated WCC, blood cultures and left knee fluid aspirate negative for organisms.
Left tibia/fibula x-ray: no sclerotic changes, no osteolytic lesions or fracture site, periosteal elevation in mid-distal
tibia.

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Clinical Station
Shin pain
How would this change your differential diagnosis and your subsequent investigations?

Given the history of trauma, fever, ESR/WCC elevation and cray changes, I would be suspicious of
osteomyelitis. Ultrasonography could highlight the presence of a fluid collection adjacent to the bone without
intervening soft tissue, as well as periosteal thickening and elevation. However, a ‘three phase’ bone scan could
reinforce the diagnosis. Focal hypoperfusion, hyperaemia and increased focal metabolic activity are diagnostic in
the absence of a fracture.

Open bone biopsy with histopathologic examination and culture is the diagnostic gold standard, but may not be
necessary if blood culture is positive and there are radiographic changes.

Do you know the names of any scoring systems for osteomyelitis?

There are multiple classification/staging systems for osteomyelitis, including the Gordon, Kelly and Cierny-
Mader classifications, which help predict the prognosis and guide timing of surgical management should it be
required.

How would you manage this patient?

I would admit the patient and start supportive therapy, including paracetamol (anti-pyretic) and intravenous (IV)
fluid. I would also discuss the case with the orthopaedic surgery registrar on call and ensure pain was sufficiently
controlled. antibiotic therapy would be started based on the identification of pathogens from bone cultures at the
time of bone biopsy or debridement. Parenteral antibiotic therapy would be started after blood cultures were
taken, and this could be changed based on sensitivity results. Traditionally, treatment would consist of a 4-6 week
course and should be according to local policy after discussion with microbiology.

The parents are very concerned about their son’s condition. They have read extensively about bone pain on the
internet and worry that this could be bone cancer. How would you counsel them?

Firstly, I would consider whether at my level, I would be the most appropriate person to speak to the parents. I
would discuss this with my senior registrar and/or consultant. If I was in a position where no senior help was
available, I would ensure that I took the parents to a quiet area or the ward or A&E department, after having first

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Clinical Station
Shin pain
thoroughly reviewed the history or results of any investigations and asking the permission of the patient to
discuss his case with his family.

I would start by checking how much information the parents would want to know about the case, as well as their
current level of understanding to ensure that my explanation and advice was appropriately complex or
simplified. I would explain that acute osteomyelitis is a bony infection, common in children and commonly
spread in the bloodstream from a distant focus, such as a small break in the skin, often from innocuous trauma,
such as experienced by their son.

I would explain that the fever and bone pain experienced by their son are common presentations and I would
reassure the parents that they had done the right thing in presenting with their child at this stage. I would explain
that antibiotics are the first method of treatment, but that if there were a failure of conservative management,
surgical therapy could be indicated.

I would address the concerns of the parents specifically with regards to bone cancer and explain we had no
suspicions of this at this stage. Regardless of this reassurance, I would explain that complications could include
the possibility of metastatic infection at distant sites, as well as spread into the joint, resulting in septic arthritis,
the development of chronic infection, pathological fracture and failure of medical management, necessitating
surgical management.

I would give the parents literature concerning osteomyelitis diagnosis, investigation and management and direct
them to relevant online materials which could aid understanding. Given the fact that family members often
would not retain all the information given to them at times of illness of a friend or relative, I would give them
contact information for a specialist nurse who would be able to give more information at a later date.

Supplementary Information

Responsible organisms usually include

• Staph aureus (80% of cases aged 4 years to adults)
• Strep pyogenes
• Haemophilus influenzae
• Gram negative organisms

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Clinical Station
Shin pain
The Cierny-Mader staging system is commonly used

I. Disease involves medullary bone and is usually caused by a single organism.

II. Disease involves the surfaces of bones and may occur with deep soft-tissue wounds or ulcers
III. Disease is an advanced local infection of bone and soft tissue that often results from a polymicrobially
infected intramedullary rod or open fracture. Stage 3 osteomyelitis often responds well to limited surgical
intervention that preserves bony stability.
IV. Osteomyelitis represents extensive disease involving multiple bony and soft tissue layers. Stage 4 disease is
complex and requires a combination of medical and surgical therapies, with postsurgical stabilisation as an
essential part of therapy.

Stage 1 and 2 disease usually does not require surgical treatment, whereas stage 3 and 4 respond well to surgical
treatment

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Clinical Station
Penetrating trauma
You are the surgical SHO on call at a District General Hospital. Whilst reviewing a non-urgent patient in A&E, a
team of paramedics present with a 19 year old with a stab wound to the right lower quadrant. It is reported that
he was in a knife fight where he was hit in the head with a heavy wooden object and then stabbed in the
abdomen. He is shouting loudly and is agitated. You can smell alcohol on his breath.

How would you proceed in this case?

I would put out a ‘2222’ trauma call to ensure that experienced help was on its way. It is likely that senior A&E
help would be nearby. If this was the case, I would ask for help immediately whilst making my way to the patient,
aware of the limitations of my own competence, and my role as part of a team to ensure optimum patient care.

I would manage this patient according to ATLS principles. This patient would be most effectively managed by
the whole ‘trauma team’, including A&E staff, anaesthetists, surgeons, etc. Depending on the seniority of those
involved, I could be involved in more of an auxiliary role in the initial management of this patient, but as the first
clinician on the scene, if I felt competent to do so, I may ‘lead’ the ‘trauma call’ and co-ordinate the rest of the
team.

The patient would likely be distressed at this point, and would need to be reassured. I would start with a primary
survey and the assessment of airway, breathing and circulation. Airway management would include visual
assessment of patency of the upper airway and removal of vomitus, blood and other foreign bodies in a position
to cause possible airway obstruction. I would assess the patient’s rate and pattern of respiration, and position of
his trachea. Assessment of his circulatory state would involve measurement of blood pressure, attachment to a
cardiac monitor and measurement of heart rate and rhythm through palpation of a central pulse.

More generally, given the mechanism of injury, I would thoroughly inspect and examine the abdomen, back and
limbs for other penetrating injuries, take the patient’s temperature and examine his pupils.

A team member would be responsible for obtaining intravenous access, through which crystalloid fluid/blood
would be given according to the level of hypovolaemic shock noted on primary survey. I would request a full set
of bloods, including FBC, U&E, clotting and a G&S. I would also make the patient nil by mouth. At this stage, I
would also give analgesia according to the WHO pain ladder, including IV morphine for its analgesic and
anxiolytic properties.

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Clinical Station
Penetrating trauma
His observations are: Temp: 36.6 Deg 146/80 HR: 116 Sats: 100% GCS: 15. What would your next steps be?

I would continue to reassess his airway, breathing and circulation as per ATLS protocols. I would try to
determine what type of weapon was used in the attack, if the patient was sufficiently composed to give a
coherent history. This is to determine the likely depth of the wound, as well as the likelihood of retained
fragments. I would request an erect chest x-ray to look for free subdiaphragmatic air or possible rib fractures. A
higher wound, (above the level of the umbilicus) would also prompt radiological examination for pneumothorax.
Plain film could also be useful for the identification of a radio-opaque foreign body.

It is unclear at this stage whether this patient would have occult internal injury, with or without ongoing
haemorrhage. Diagnostic peritoneal lavage (DPL) has now been superseded by FAST scanning in A&E
departments.

You repeat the observations, five minutes after your previous test. The patient is still very vocal, but his speech
is now confused. He is increasingly combative. He complains of worsening pain in his right upper quadrant. On
palpation, he becomes aggressive and tries to strike members of the clinical team

Observations: Temp: 36.6 Deg 135/70 HR: 123 Sats: 97% GCS: 14 FAST scan: An anechoic strip is seen in
Morison’s pouch.

Given the change in clinical picture, what form of radiological imaging do you think would be most
appropriate?

Further imaging at this stage would NOT be

appropriate. This patient is young, with significant
biochemical reserves. Despite this, he is showing signs of
developing haemodynamic instability. An urgent
exploratory laparotomy would be indicated. As the
SHO, I would ensure that O negative blood was
available, pending the arrival of blood from the cross-
matched sample and would alert theatre staff to the
imminent arrival of the patient.

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Clinical Station
Penetrating trauma
Supplementary Information

The focused assessment with sonography for trauma, commonly abbreviated as the FAST scan, is a rapid bedside
ultrasound examination which has become a mainstay of assessment of the management of intra-abdominal
penetrating injury and the identification of haemoperitoneum. A positive FAST scan is characterised by fluid
collection in dependent areas of the peritoneum. In the RUQ (classically hepatic injury), this typically appears in
Morison’s pouch, between the liver and the kidney. In the left upper quadrant, this collection is in the perisplenic
space. In the pelvis, fluid collects in the retrovesical space.

FAST scanning has superseded DPL is many centres as it does not involve irradiation and is less invasive. A
positive FAST scan with haemodynamic instability should be managed by emergency laparotomy +/- proceed.
Abdominal CT scan may be used if the patient is stable, but this decision should be taken at a senior level.

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Clinical Station
Post CABG complications
You are the cardiothoracic SHO on call. You are asked to review Mrs Jones, a 76 year old lady who is 30 hours
post coronary artery bypass grafting (CABG) for three-vessel coronary artery disease. She has a history of
hypertension and AF, for which she was on long-term warfarin pre-operatively. This was reversed before her
procedure and her pre-op INR was 1.0.

She has had a good post-operative course and was extubated 5 hours previously. The nursing staff are concerned
because of her low blood pressure. Her CVP and radial arterial line remain in situ. Her ionotropic demands have
increased over the past 4 hours. A left pleural and mediastinal chest drain remain in situ. Both have negligible
output in the last 2 hours.

Her observations are as follows: BP: 95/60 (from 120/85 one hour previously), HR: 110, RR: 19 sats 96%. Cool
peripheries. GCS: 14 (confusion). Urine output: 20 and 10 mls/hour in the previous 2 hours.

What would be your concerns and how would you further assess the patient?

My main concern in a post-operative cardiac patient would be cardiogenic shock secondary to tamponade or
early graft failure resulting in myocardial ischaemia. I would also be concerned about hypovolaemic shock,
tension pneumothorax and cardiogenic shock, as a result of excessive fluid administration or a primary cardiac
event. Whilst pulmonary embolism could fit with the clinical picture, it would be unlikely given the heparisation
of cardiac patients perioperatively.

Post-operative cardiac tamponade is a surgical emergency. I would contact the cardiothoracic registrar as a
matter of urgency. I would order an ECG and assess the features of ‘Becks Triad’. I would assess the trend in the
patient’s blood pressure over the preceding few hours, noting her history of hypertension and the fact that her
current reading could signal a severe relative hypotension on a hypertensive background. I would auscultate her
chest and inspect her neck for signs of jugular venous distension, as well as inspecting the CVP trace. Pulsus
paradoxus would further confirm my diagnosis and I would ask the patient to take a deep inspiratory breath
whilst monitoring the BP if the patient was able to complete this.

Quiet or muffled heart sounds or a drop in inspiratory BP by > 10mm Hg would support the diagnosis of cardiac
tamponade. Deviation of the trachea from a central position could support an alternative diagnosis of tension
pneumothorax, although the time-course of symptoms progression would not correlate with this.

I would take an arterial blood gas sample from her arterial line. This would give me information about arterial
oxygenation and Haemoglobin (Hb). A low arterial saturation would not be wholly discriminatory, and would in
some cases correlate with occult blood loss, pneumothorax or pulmonary embolism. However, if pulse oximetry,
or the arterial gas suggested hypoxia, I would start oxygen via nasal cannulae or a facemask. A serial drop in Hb
would correlate with cardiac tamponade or other occult post-operative blood loss.

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Clinical Station
Post CABG complications
The patient has muffled heart sounds on auscultation of the chest. There is still no output from her chest drains
and her blood pressure does not improve despite an initial 250ml gelofusine bolus given by the Intensive Care
nursing staff just before your arrival. Her CVP measurement remains high.

Which investigations would you order for this patient and how would you proceed?

I would take a full set of bloods from the patient, including a coagulation screen. I would check the validity of the
previous crossmatch. Creatine kinase and troponin-I measurements would be of no benefit at this stage as they
would be elevated in the post-operative patient.

I would continue fluid resuscitations with blood or 250ml gelofusine boluses in the absence of a known history of
poor left ventricular function. Further ionotropic medications could be considered. I would also consider
ordering a mobile plain chest x-ray if I felt that the patient was stable enough for a delay whilst waiting for this
investigation. I would discuss all of these measures with the cardiothoracic or intensive care registrar on call.

What would an echo show in cardiac tamponade?

An echocardiogram could be used to visualise ventricular and atrial compression abnormalities during the
passage of blood through the chambers of the heart or diastolic collapse. I would contact an appropriate senior
member of staff to get either a transthoracic echocardiogram (TTE) or a transoesophageal echo (TOE) if the
expertise was available. Despite the value of these investigations, the diagnosis of cardiac tamponade is a clinical
diagnosis and I would ensure that I had senior surgical and anaesthetic input from the outset.

How would this patient be managed?

Non-surgical cardiac tamponade is managed via a pericardiocentesis. However, this post operative patient would
likely have a pericardial collection due to haemorrhage, clot formation in the pericardial sac and blockage of the
outflow into the drains. If tamponande was suspected clinically, this patient would need to be returned to theatre
for a re-do sternotomy and removal of clot in the pericardial sac.

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Clinical Station
Post CABG complications
Supplementary Information

Cardiac tamponade is pressure on the heart which occurs when fluid collects in the pericardial space, impairing
the ability of the chambers of the heart to contract and to stretch normally and impairing cardiac filling in
diastole. There are a number of non-operative causes including hypothyroidism, penetrating trauma and
pericariditis. It is a challenging diagnosis, often due to the complex nature of the patients and ITU environment
and remains a clinical diagnosis. If untreated, tamponade will lead to arrest, with PEA the likely presenting
rhythm.

Imaging in tamponade

Chest x-ray may show cardiomegaly, with a ‘water bottle shaped

heart’, pericardial calcification or evidence of chest wall trauma. It
could also highlight a widened mediastinum or a large pleural
collection.

12 lead ECG can highlight features that are suggestive, but not diagnostic of pericardial tamponade. These
include sinus tachycardia, low voltage ECG complexes and PR segment depression.

The key to successful management of cardiac tamponade is early recognition. If you have a suspicion about this
diagnosis, especially in a post-operative patient, speak to a senior colleague urgently.

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Clinical Station
Swollen Testicle
You are the general surgical SHO. You are called to see a 27 year old man who has presented to A&E
complaining of a painless swelling in his right testicle which he noticed in the shower 4 hours previously. He is a
keen footballer and has noticed an intermittent ‘dragging sensation’ in his scrotum over the past 3 months. He
denies fever, weight loss or bony pain. He is very anxious.

What diagnoses would you consider? Which of your differential diagnoses would be most concerning?

I would consider testicular torsion, although the presentation of painless swelling does not fit with this. This is a
surgical emergency and so would need to be excluded immediately. Given the presentation and age of the
patient, malignancy is an important differential diagnosis to consider early. Other differential diagnoses include
hydrocele, varicocele, spermatocele, haematoma, epididymitis and inguinal hernia

The key to diagnosis would be a complete history and bimanual examination of the scrotum, abdomen and
chest, inspecting particularly for evidence of metastatic disease and systemic features of hormone secreting
tumours such as gynaecomastia.

The left testicle is normal and non tender. The right testicle has a 2cm spherical rubbery mass at the apex. The
testis and epididymis separately definable. The mass is non tender and does not transilluminate. The swelling is
confined to the scrotum.

How would you examination findings refine your differential diagnosis?

Testicular tumour would remain my working diagnosis given the findings of a discrete, rubbery, non tender
testicular mass,
Testicular torsion can be excluded in the absence of pain and definition of the testes and epididymis. Similarly,
epididymo-orchitis is classically associated with pain and tenderness. Importantly, if I had any doubt about the
diagnosis of testicular torsion, I would request immediate review from my registrar as early intervention in
torsion is essential. A hydrocele would transilluminate and the testes and epididymis would not be easily defined
on palpation. The swelling of inguinal hernia would not be localised to the scrotum and would not be associated
with a discrete mass as in this case.

At the end of your examination, the patient becomes tearful. He explains that a close friend of his has recently
been diagnosed with testicular cancer and he is ‘convinced’ that is the cause of his lump. He urges you just to
‘be honest with him’ How would you deal with this?

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Clinical Station
Swollen Testicle
I would ensure that we were in a quiet and private environment and would try to calm him. I would ask if he
wanted me to call any family members or friends. I would try to assess the level of his current understanding and
ask how much information he would like about his case, before explaining the fact that we were not yet at the
point of a confirmed diagnosis and that we would need to complete more investigations before we would be at
that stage.

However, I do think it would be appropriate to address his ideas and concerns at this stage regarding testicular
cancer itself, especially if he had heard or read misleading information from friends or the internet, or believed
for example that testicular cancer was incurable. I would assure him that we would be honest when we did have a
confirmed tissue diagnosis, whilst reassuring him that there were a number of therapies available to him, even if
his worst suspicions were confirmed.

I would check his understanding of our discussion and make sure that I came back later to check that he had
been reassured and answer any other questions he may have.

How would you investigate the mass?

I would order a baseline set of bloods (including FBC and basic metabolic bloods), as well as serum tumour
markers specific to testicular cancer; alpha fetoprotein, beta HCG and LDH.

My radiological investigations would start with a scrotal ultrasound, which would evaluate the location, size and
characteristics of the lump. This patient would need to be discussed both with the surgical and oncology
specialists and would likely be referred for specialist care if malignancy was suspected. However, CT scanning of
the abdomen and pelvis would have a role in evaluating the presence of metastatic disease, particularly in the
retroperitoneum. Chest x-ray would highlight pulmonary metastases.

Baseline bloods: Normal. AFP: Normal LDH: 253 bHCG: 8000 mIU/ml, (normal: <5mIU/ml). Scrotal USS shows
a 2cm solid mass in the right testes.

CT: 6 mm pelvic retroperitoneal lymphadenopathy with no evidence of visceral metastases.

CXR: No pulmonary nodules.

How would a definitive diagnosis of testicular cancer be made?

A confirmed diagnosis would require histology from a tissue sample. This would be obtained from the surgical
excision of the entire testes along with the epididymis and spermatic cord.

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Clinical Station
Swollen Testicle
Would you consider obtaining a tissue sample from a biopsy? What are the additional benefits of radical
inguinal orchidectomy?

No. A biopsy could cause seeding of the cancer cells from the testes itself into the scrotal sac. Radical inguinal
orchidectomy provides both histological identification, but also local tumour control.

Pathology results confirm a well differentiated seminoma.

What treatment plan would be started by the oncology team?

After the removal of the affected testis by radical inguinal orchidectomy, early stage seminoma would be treated
by radiation therapy directed towards the para-aortic lymph nodes. Cure rates are reported to be in the region of
95%, with recurrence rates of 5-15%. Alternatively, surveillance with close follow-up may be selected for small
<3cm seminomas with favourable histologic features and negative post-operative serum tumour markers. For
higher stage tumours, radiation therapy would still be considered, though chemotherapy would be indicated for
bulky, recurrent or advanced disease.

Supplementary Information

Testicular cancer is the most common malignancy in young men with the highest incidence in Caucasians in
Northern Europe or the U.S. There are 1400 new cases per year in the UK. Peak incidence in the UK is at age
25 for teratomas and 35 for seminomas. There is 95% 5 year survival for disease localised to the testis with no
metastasis. Due to advances in chemotherapy, treatment of testicular cancer has been labeled one of the ‘success
stories of modern medicine’. Cure rates approach 85% in all cases, with better than 95% for localised disease
and 80% for metastatic disease- the best response for any solid tumour.

Classical presentation is with painless mass or swelling, but pain can occur. Gynaecomastia is caused by bHCG
production. Seminomas metastasise to para-aortic lymph nodes and produce back pain, whereas teratomas are
blood borne and spread to the liver, lungs, bone and brain.

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Clinical Station
Swollen Testicle
Royal Marsden staging of testicular tumours:

I No evidence of disease outside the testis.

IM - as above but with persistently raised tumour markers.

II Infradiaphragmatic nodal involvement

IIA - maximum diameter <2 cm.
IIB - maximum diameter 2-5 cm.
IIC - maximum diameter >5-10 cm.
IID - maximum diameter >10 cm.

III Supradiaphragmatic and infradiaphragmatic node involvement

- subclassifications A,B & C based on diameter of abdominal node as above
M+ - mediastinal nodes involved
N+ - neck nodes involved

IV Extralymphatic metastases
- subclassifications A,B & C based on diameter of abdominal node as above
M+ - mediastinal nodes involved
N+ - neck nodes involved

Lung involvement:
L1 <3 metastases
L2 multiple metastases <2 cm maximum diameter
L3 multiple metastases >2 cm in diameter

H+ Liver involvement

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Clinical Station
Paediatric hernia
You are the paediatric surgical SHO on call. You are called to see a 6 month old girl of West African origin who
has been brought in by her parents as they are concerned about a ‘bulge’ in their daughter’s mid-abdomen when
she cries or coughs. She was born at 36 weeks, is otherwise healthy, and is meeting growth and development
targets. The ‘bulge’ always goes down when she is calm or sleeping. She is eating well and there has been no
change in her bowel habit.

On examination: 115bpm. Respiratory rate is 30 breaths per minute. BP 90/55. She is afebrile

How would you proceed?

I would ensure that the child is stable using an ABCD approach. Given that all of her observations are normal
for her age, I have no concerns at present and would reassure the parents of this. I would take a full history and
proceed to examination of the child.

On examination:

The child is playful and in no apparent distress or pain. After being placed
on the examining table, the child starts to cry. You note a 2cm x 2cm peri-
umbilical mass protruding on crying, most easily reducible on gentle
palpation when the patient is calm. There is a 1cm x 1cm palpable umbilical
defect at rest.

What is your diagnosis?

The history and examination would support a diagnosis of umbilical hernia.

What are the risk factors for the development of this condition?

Congenital umbilical hernia is a present in up to 30% of babies. It is caused by a failure of the umbilical ring to
completely close over. Boys and girls are equally affected. Risk factors for this include prematurity, low birth
weight, African origin and Down's syndrome.

Amongst adults, it is three times more common in women than men, with a slight female preponderance
amongst infants. [In adults, an acquired umbilical hernia can be caused by increased intra-abdominal pressure
due to a chronic cough, multiparity, obesity or straining during heavy lifting].

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Clinical Station
Paediatric hernia
What are your differential diagnoses?

Umbilical hernia would fit with the presentation. It would need to be differentiated from paraumbilical hernia in
adults. Cysts of the vitello-intestinal duct could also present similarly in some cases.

In a child of this age, what would be the recommended course of management?

90% of small (1-2cm) umbilical hernias close within 3 years. They have a low risk of incarceration or
strangulation. In the absence of abdominal distention or constant pain indicating visceral compromise,
observation is recommended.

You see a similar patient in a well child clinic. She is 18 months old and was advised about conservative
management of umbilical hernia at 5 months of age. The parents are very concerned about the persistence of
this lump when she coughs and strains and are wondering if surgical management is necessary. What would
you advise?

I would reassure the parents. The diagnosis and recommended management would be unchanged at this age.
The exact age at which operative management is indicated is disputed. Operative management is often delayed
until at least 3-4 years of age. At this stage, more than 85% will have spontaneously closed. Around this age, the
chance of spontaneous closure would decrease, with an increase in the likelihood of incarceration. At 18 months
of age, continued observation would be reasonable.

What causes this condition?

Paediatric umbilical hernia is caused by a failure of timely closure of the umbilical ring, leaving a central defect
in the linea alba. This fascial defect allows visceral protrusion. Adult umbilical hernia is a different pathological
entity.

Supplementary Information

Omphalocele is a differential diagnosis for umbilical hernia in the newborn. It is a congenital midline abdominal
wall defect at the base of the umbilical cord insertion with visceral herniation from the foetal abdomen. This
would be classically associated with other gastrointestinal abnormalities and up to 50% of these patients would
have associated cardiac abnormalities. It is associated with significant morbidity and mortality

Operative closure of this abdominal wall defect should be performed shortly after diagnosis as it can lead to
significant fluid loss. Primary closure of the defect may be problematic after repair due to bowel oedema in a
relatively small abdominal cavity, therefore a system of ‘staged repair’ is often used.

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Clinical Station
Epigastric pain
You are asked to see a 59 year old woman who has attended Accident & Emergency with severe epigastric pain
spreading to her back pain and difficulty in breathing. She has been vomiting for the last hour and denies any
recent change in her bowel habit. She has a history of excess alcohol consumption and has been experiencing
difficulty in swallowing over the last few weeks.

What would be your differential diagnosis and what other aspects of the history would you clarify?

Severe epigastric pain following several episodes of vomiting is characteristic of Boerhaave syndrome
(oesophageal rupture following vigorous vomiting). The classical features of this include excruciating retrosternal
chest and upper abdominal pain, ondynophagia, tachypnoea, dyspnoea and signs and symptoms of shock. Her
history of excess alcohol predisposes her to gastritis, gastric ulcer disease and Barretts Oesophagus, risk factors
for Boerhaave syndrome.

Other differentials include pancreatitis, peptic ulcer disease and oesophageal spasm. I would take a detailed
history about the content of the vomitus. Haematemesis may suggest a Mallory Weiss tear, upper GI bleed or a
vascular malformation of gastrointestinal tract, such as bleeding gastric or intestinal varices. I would also consider
an atypical presentation of a cardiac aetiology, such as an acute coronary syndrome.

How would you manage this patient?

Taking an ABCDE approach I would sit the patient upright and apply oxygen via a face mask and gain IV access
with a large bore cannula. I would take bloods including an FBC, U&E, amylase, clotting and G&S. I would
immediately resuscitate the patient using colloid or crystalloid solutions if I believed her to be clinically shocked. I
would then contact my registrar for advice as this patient is unwell. I would involve critical care early by
contacting HDU to assess the number of beds available in case the patient needed to be escalated swiftly.

I would make the patient nil by mouth, and commence antibiotics if necessary.

What investigations would you arrange?

I would organise a portable erect CXR to look for pneumoperitoneum that could highlight a perforated viscus. I
would look for pneumomediastinum and pleural effusions which are usually left sided in oesophageal rupture.
Although not common in the acute scenarios these patients can also present with a pneumothorax and soI would
check the CXR for this. The gold standard investigation is a water soluble contrast such as gastrograffin to
delineate the defect in the gastrointestinal tract.

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Clinical Station
Epigastric pain

What does this image show? Does it support any of your differential
diagnoses?

This image possibly from a gastrograffin x-ray shows extra-luminal contrast

arising from a left, posterolateral tear of the oesophagus. It supports a
diagnosis of oesophageal rupture.

What other investigations would you order?

A CT should follow to help further assess the defect but may also identify underlying malignancy that may have
precipitated the oesophageal rupture. An endoscopy can identify where the defect is but should be performed
with caution as it may cause further disruption of the defect.

What is the definitive management for this diagnosis?

The definitive management is the surgical closure of the oesophageal defect. Small oesophageal defects in a
haemodynamically stable patient can be managed conservatively with serial haemodynamic assessment and
radiological monitoring. Surgical techniques include repairing the defect, insertion of a stent over the defect,
resection or insertion of a drain from the defect to the external environment.

Supplementary Information

Oesophageal rupture is due to iatrogenic causes such as endoscopy in 75% of cases. Boerhaave syndrome is the
spontaneous rupture of the oesophageal wall often secondary to volatile vomiting. This is usually after excess
alcohol consumption. Other causes include ingestion of caustic agents or foreign bodies that interrupt the
oesophageal wall. Oesophageal rupture tends to affect the left posterolateral wall of the oesophagus. These
patients can present with an array of symptoms which can make it confusing to isolate the diagnosis. It is usually,
but not exclusively found in men.

Macklers triad consists of three key symptoms that occur in oesophageal rupture, chest pain, vomiting and
subcutaneous emphysema. Often these symptoms overlap closely with cardiovascular and respiratory pathology
and so a thorough history is important. Remember to ask about predisposing factors such as a history of excess
alcohol intake, Barrett’s oesophagus and GORD. It is important to start the patient on antibiotics early as often
hours to days later patients can develop mediastinitis.

90% of all tears occur in the left posterolateral wall of the distal oesophagus.

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Clinical Station
Epigastric pain
Advice

This is a surgical emergency and must be taken seriously. The patient can rapidly develop hypovolemic shock and
serious airway problems as oesophageal contents leak into the thoracic cavity. Your aim should be to initially
resuscitate the patient and immediately escalation to a senior as in some cases the lifesaving treatment is urgent
surgery by an experienced surgeon.

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Clinical Station
A child with a fracture
You are the orthopaedics SHO on call. You have been asked to see a 6 years old boy in the Accident and
Emergency Department (A&E) who sustained a right elbow fracture after falling from a height of 9 feet. On
arrival in A&E, you see the boy with his parents in a bay. He is crying and there is an obvious deformity of his
right elbow.

What would be your approach to management of this patient?

I would introduce myself and confirm the patient's and his parents' identity. I would then assess the patient
according to the ATLS protocol.

Firstly I would assess his airway making sure it is patent and that he has adequate C-spine stabilisation. He is
crying hence it is re-assuring that he has a patent airway. If there were any signs of airway obstruction or
concerns of impending obstruction I would maintain his airway with a jaw thrust and consider simple airway
adjuncts such as a Guedel airway if necessary. I will also seek help from the anaesthetist immediately.

I would then assess his breathing by clinically assessing his breathing efforts. I would look for signs of respiratory
distress such as tachypnoea, intercostal recession, use of accessory muscles, grunting, gasping, noisy breathing
and central cyanosis. I would also measure his oxygen saturation using a pulse oximetry and examine his chest to
listen for any reduced, asymmetrical or bronchial breath sounds and other added sounds such as wheeze or
stridor. If there were any signs or concerns of compromised breathing I would start him on high-flow oxygen via
non-rebreathing mask and call the anaesthetist for help immediately.

After establishing that this child has a good airway and breathing well, I would assess his circulation to ensure he
is haemodynamically stable and well perfused. I would check his capillary refill time, pulse, blood pressure and
look for clinical signs of dehydration which include reduced skin turgor, dry mucous membrane, reduced urine
output and thirst. This child will need intravenous access and urgent blood samples to be taken. If there were any
signs of shock I would start this child on fluid replacement regime.

Next I would examine his neurology status by determining his GCS level or using AVPU scale and checking
pupillary reflex. I would also ensure his blood glucose levels are normal. After this I would perform examine the
right elbow and then perform a full examination of this child to rule out presence of other injuries. I would
explain what I am doing as I go along to the patient and his parents.

While assessing this patient you find that he has a respiratory rate of 22, heart rate of 130 and a blood
pressure of 100/50. He also has dry mucous membranes and complaining of thirst. He already has intravenous
access and you decide to fluid resuscitate him.

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Clinical Station
Child with a fracture
How would you decide how much of fluid you are going to administer and which type of fluids to prescribe?
(Patient’s weight = 22kg)

In a situation when a child is acutely dehydrated, he will need both maintenance fluids and rehydration. In this
scenario, this child is moderately dehydrated which equates to 5-10% dehydrated.

To calculate fluids for rehydration:

Percentage dehydration x weight in kg x 10
5% x 22 x 10 = 1100 mL

To calculate for maintenance fluids:

First 10kg give 100mL/kg/day = 4mL/kg/hr
Next 10kg give 50mL/kg/day = 2mL/kg/hr
Above 20kg give 20mL/kg/day = 1ml/kg/hr

First 10kg:
10 x 100 = 1000 mL/day
10 x 50 = 500 mL/day
2 x 20 = 40 mL/day

Total maintenance fluids = 1000 + 500 + 40

= 1540 mL/day

The volume for rehydration in addition to the maintenance fluids should be given over 24 hours.

Total fluid to be given over the 1st 24 hours = Fluids for rehydration + maintenance fluids
= 1100 + 1540
= 2640 mL/24hours

Assuming this child has normal U&Es, I would prescribe dextrosaline mixture of 5% glucose and 0.45% saline
with 10mmol of potassium chloride in each 500mL bag. If there are any electrolyte disturbances present I would
liaise with my paediatrician colleagues prior to deciding on the type of fluids to administer.

How will you assess this child's right elbow injury?

I will take a full history in particular mechanism of injury and previous injury and fractures this child has had. I
will then examine his upper limbs, assessing the neurovascular status and range of movements of the joints of the

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Clinical Station
Child with a fracture
upper limbs. I will also examine this child fully looking for any other injuries that may be due to trauma but also
keeping in mind the possibility of non-accidental injuries. After completing my clinical assessment I would obtain
radiographic imaging of the limb(s) affected which include an AP and lateral view. I will ensure that I record my
findings carefully in the patient's notes.

Further examination of this child revealed linear whip marks and finger mark bruising over his torso.

What are your concerns and how will you deal with it?

My main concern is the presence of non-accidental injuries. I would enquire the history of how this child
obtained these injuries both from the child and the parents in a non-judgemental manner. I would also assess the
appearance and behaviour of this child and the interaction between the child and his parents. Based on my
findings I would consider my level of concerns regarding child abuse and risk of any immediate harm to the
child. I would document my concerns in detail in the patient’s medical notes and inform a senior colleague and
the paediatrics registrar or consultant on-call prior to discussing this sensitive issue with the parents or social
services.

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Clinical Station
Post operative confusion
You are the general surgery SHO on-call at night. You have been called by the nurses on the general surgical
ward regarding a 68 year old patient who has been confused since late afternoon. She has been wondering
around the corridors and refuses to return to her bay. She gets very agitated when the nurses try to persuade
her to go back to bed and the nurses want you to prescribe medications to calm the patient down.

What would you do?

Whilst on the phone I would make an initial assessment by asking about her observations and ensure that the
patient is clinically stable. I’d go to the ward to assess the patient at the first opportunity I had, and certainly
before prescribing any medications. Once there, I would recruit the expertise of the nursing staff to help bring
the patient to a safe place. If the patient was very aggressive I would seek advice from the registrar on-call and
get help from security at an early stage.

Once safe I would assess her, clinically and try to find out from her what is causing her to be distressed. Assuming
her ABC’s are stable (and if not I would measure and treat as per ATLS) I would assess her confusion, by
assessing her GCS. A BM measurement is essential at this stage.

Once I’m convinced she is safe I would also go through her medical notes, recent blood tests and other
investigations to find out whether her confusion was new and if she has had any predisposing factors such as
recent surgery, critical care admission or a catheter that could have increased the possibility of an infection. I
would gather all the information, make my own assessment then discuss the case with my registrar.

Once a reversible cause for her confusion is found she will need to be started on treatment for it. If there were no
obvious causes and there were no surgical causes for her confusion this lady will require input from the medical
team for ongoing care.

She may need medication temporarily to keep her calm and I would seek advice from the medical registrar on-
call regarding medications suitable to prescribe for this lady.

You examine this lady and find that she is pyrexial at 38.5 degrees Celsius, has a heart rate of 130, blood
pressure of 90/60 and respiratory rate of 22 breaths per minute. ECG shows fast atrial fibrillation and her
known past medical history includes hypertension, ischaemic heart disease and type 2 diabetes. You also noted
that she is day 5 post-operation. She had a low anterior resection for a malignancy and her surgical wound has
pink fluid oozing from it. She

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Clinical Station
Post operative confusion
is very tender on palpation of her abdomen. Nurses reported to you that she has not been eating and drinking
much and has not open her bowels yet.

How are you going to manage this situation?

I will manage this lady first according to the ALS guidelines. This lady has signs of shock likely secondary to post
operative abdominal sepsis. This lady needs fluid resuscitation and I will initially give her a bolus of intravenous
fluid to assess her response. If she responds well she will require maintenance fluid and if not she will need
further boluses of intravenous fluids. I will also perform an arterial blood gas to assess her metabolic status and
respiratory function. Then I will immediately inform my registrar about her as she is unwell and as per my
registrar’s advice, arrange for an urgent abdominal CT scan. I would seek microbiology advice regarding
empirical antibiotics and ask the critical care outreach team to assess her. I would also ask the nurse to perform
hourly observations, and assess her myself again regularly.

The investigations results are as follows

ABG:
pH 7.29
PaO2 11.7 kPa
PaCO2 3.9 kPa
HCO3- 10 mmol/L
BE -4
Lactate 7

Bloods
Hb 120
WBC 18
Platelets 700
Neutrophils 8.5

Na+ 143
K+ 4.2
Urea 17 (baseline ~ 6)
Creatinine 190 (baseline ~ 70)
CRP 186

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Clinical Station
Post operative confusion
What do the results show?

This lady has raised inflammatory markers showing likely infection and she has developed a metabolic acidosis
secondary to sepsis and is trying to compensate by increasing her respiratory rate. She is in acute renal failure.

Her CT scan showed intra-abdominal collection. You inform your registrar regarding this however he is
currently scrubbed in theatre for another emergency case and is unable to review the patient but asks you to
consent the patient for an emergency laparotomy and discuss with HDU for a bed post-operatively. You are
not trained to take consent yet and the hospital policy is for at least a registrar review for any patient to be
referred to HDU and ICU.

What would you do?

I’m not competent to take consent and therefore have to inform my registrar of this. Instead I will try to facilitate
the surgery by booking the case onto the emergency list and informing the anaesthetic and theatre team. I will
aid the consent process by getting the consent form ready and inform the patient and family about her current
clinical situation.

Regarding the consent, this lady appears confused but ideally her wishes and her next of kin and family’s views
should be consulted. In emergency situation like this one we would treat her in her best interests. The patient will
probably require a consent 4 form if she is unable to understand, weigh, retain the information or communicate
her decision.

I would also ensure the patient is optimised for surgery, and contact the critical outreach team for their support. I
would escalate to the consultant on-call immediately as this patient is critically unwell and will need urgent senior
review. If I am unable to get in touch with the consultant on-call, I will then contact the consultant who is
responsible for this patient’s care to ensure patient care is not delayed.

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Clinical Station
Wounds and dressings
How would you classify a wound?

One can classify a wound by type, thickness, and age.

Type describes how the wound was created. For instance; abrasions (superficial), incision (from a surgeon’s knife),
laceration (often confused, but an irregular wound caused by a sharp object on soft tissue), crush (heavy blunt
objects, such as a falling tree on your leg), stab, puncture, bullet, bite and burns (thermal, chemical or electrical).

Depth of the wound, like the classifications of burns can be separated into superficial, partial thickness and full-
thickness. Superficial wounds affect the epidermis and the upper dermis. Partial thickness wounds contain
damaged tissue up to the subcutaneous tissue. Full thickness wounds involving all layers of the skin and
subcutaneous tissue, down to fat and bone. Wounds can also extend down to or through organs.

Classification by age as clinical significance as older wounds are less amenable to primary surgical closure, and
susceptible to contamination or tissue necrosis.

How might you classify wound healing?

There are three types of wound healing. Healing by first intention is where the wound is closed by opposing the
tissue margins surgically, most commonly with sutures, clips or steristrips or by using tissue grafts from other sites.
Healing by secondary intention is where the wound is left open so that granulation tissue can gradually fill the
intervening gap and close the wound without surgical intervention. Healing by tertiary intention represents
delayed closure, where the wound, usually because of contamination is deliberately left open to heal, and then
closed at a later date once sufficient granulation tissue has occurred and the infection resolved.

What are the stages of wound healing?

The phases of wound healing include an inflammatory phase, a proliferation phase and a maturation phase.

What factors affect wound healing?

Both intrinsic and extrinsic factors affect wound healing.

Intrinsic factors include the type, depth, age, size and anatomical location of wound. Tibial lacerations for
instance are partially susceptible to slow wound healing due to thin tissue layers and poor vascular supply. Local
infection of the wound is perhaps the most common reason for poor wound healing.

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Clinical Station
Wounds and dressings
External factors include the patient’s clinical and nutrition status, their age, the presence of co-existing systemic
infection or disease and the therapy they are receiving. Steroids and radiotherapy are particularly detrimental to
wound healing. Co-morbidity such as diabetes mellitus, heart disease, smoking, and vitamin deficiencies C and K
also can delay wound healing significantly.

What operations are clean and what are considered contaminated?

Clean operations are non-traumatic operations that don’t enter the respiratory, gastrointestinal or genitourinary
tracts. Clean contaminated operations are non-traumatic operations which involve respiratory, gastrointestinal or
genitourinary tracts. Contaminated operations include fresh traumatic wounds from a clean source or significant
involvement of the respiratory, gastrointestinal or genitourinary tracts. Dirty wounds are traumatic wounds from
an unclean source or traumatic wounds with delayed closure.

Why might one debride a wound?

To ensure adequate wound healing, the wound edges and base need to be clean and have an appropriate vascular
supply to ensure an adequate supply of nutrients, cells, and allow growth and immune factors to enter the
wound. If the wound has become infected, necrotic or non-viable tissue then this will inhibit good wound
healing. Surgical debridement aims to remove this infected, necrotic or non viable tissue to allow optimal wound
healing.

Why do we use wound dressings?

Wound dressings protect the wound from contamination, help alleviate pain, and reduce moisture loss.

What is the ideal characteristics of a wound dressing?

This is relatively similar to the ideal characteristics for suture material, essentially it should be inert, not
promoting inflammation or allergic reaction. It should ensure adequate protection from contamination from
bacteria and dirt, keep the wound moist, adherent but allows mechanical movement, absorbs exudate, pus and
odour from the wound and be cost effective and relatively simple to apply.

What are the different types of wound dressings and what different types of wound dressings do you know?

Wound dressings can be synthetic (most dressings), non-synthetic (skin grafts), temporary (most dressings) or
permanent (skin grafts).

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Clinical Station
Wounds and dressings
Types of wound dressing include:

Cotton gauze
Impregnated gauze
Hydrocolloids
Silicones which act similarly to skin in allowing adequate mechanical movement and wound protection but little
absorptive capacity.
Barrier films
Tissue adhesives (such as tissue glue found in emergency departments for superficial wounds)
Hydrogels which contain significant percentage of water, useful in dry and necrotic wounds to keep the healing
area moist.
Hydrocolloids which are good at absorbing fluids
Alginates that are useful in the most exudative of wounds, for instance following incision and drainage of an
abscess.
Vacuum dressings, which are usually film dressings with the addition of a pump to create a negative pressure
vacuum around the wound site, with the aim of encouraging the excretion of exudate and pus to speed wound
healing.

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Clinical Station
Epigastric Pain II
You are telephoned to see a 65 year old man presents to A&E, as the general surgery SHO on call. A&E report
that on examination, the patient looks unwell. He is pale and clammy, with marked epigastric tenderness. He
has vomited once. He is normally fit and well, although is troubled occasionally by mild upper abdominal pain
after eating. He smokes socially and admits to drinking more than he should, four or five pints most evenings
after work.

What are your differentials?

Using a systems' approach, my differentials would be as follows: gastrointestinal causes might include peptic
ulceration with or without perforation, pancreatitis, appendicitis or bowel obstruction. Of these, pancreatitis or
peptic ulceration seems most likely, because of the history of epigastric pain and alcohol excess. Biliary causes
include gall stones and related complications. Urological causes include renal colic or a pyelonephritis.
Cardiovascular causes would include an abdominal aortic aneurysm or myocardial infarction, which would be
important to exclude given the smoking history. Finally, in the respiratory system, a lower lobe pneumonia could
cause referred pain in the abdomen, however this is unlikely as there is no mention of respiratory symptoms.

Advice

Always structure your answer when asked to list potential diagnoses and give the more obvious ones first. Provide
simple justifications for your answers - one sentence, or two, just enough to show that you have taken the history
and examination into account, rather than only hearing "epigastric pain".

The suspicion is of pancreatitis. How would you approach the patient initially?

Over the phone I would ask for the initial observations and take a quick history so that I could ascertain whether
immediate escalation was required. Once with the patient, I would assess his airway, breathing and circulation
according to ALS principles, while simultaneously initiating resuscitation.

Airway - I would ensure no comprise, e.g. from vomiting, and apply high flow oxygen.
Breathing - I would looks for signs of respiratory distress, including assessing oxygen saturations, respiratory rate
and auscultation of the chest.
Circulation - I would look for signs of haemodynamic instability. I would gain intravenous access and send off
haematological investigations as appropriate, following this I would start aggressive fluid resuscitation with
crystalloid boluses, aiming to achieve a urine output of at least 0.5ml/kg/hr.
Disability - I would regularly assess the patient's consciousness level, ensuring they had adequate analgesia
according to principles of the WHO analgesic ladder, and I would monitor blood sugars.
Exposure and everything else - I would palpate the abdomen, looking for signs of peritonism or bruising. With a
diagnosis of pancreatitis in mind, I would start intravenous pantoprazole, while keeping the patient nil by mouth.

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Clinical Station
Epigastric Pain II
I would pass a nasogastric tube and insert a urinary catheter. I would organise timely investigations, including
erect chest x-ray, ultrasound and abdominal CT.
I would liaise with my seniors and my intensive care colleagues as this patient needs at least HDU care.

Advice:

The text above is written as 'Airway - Breathing - ' etc. for ease of reading. When answering in real life, make the
transition between each smoother. For example, "moving on to assess breathing, I would...".
The clue is the the question - "the suspicion is of pancreatitis". Do not be afraid to tailor your answer to this.
As always, coherent, concise, un-rushed presentation is crucial. You want the examiner to feel that the calm they
see before them is the level of calm you would demonstrate in a pressured situation like the one described.

Tell me in more detail what investigations you would consider?

I would divide investigations into four categories; simple, bedside tests, haematological, radiological and more
specialised tests.
At the bedside I would ensure a urine dip was performed, looking particularly for blood, protein or sign of
infection. I would ask for basic observations, a blood glucose and a 12-lead ECG.
Among my blood tests I would include an FBC, U&Es, LFTs, amylase, a blood gas (pH, calcium, lactate),
coagulation, group and save. These would enable me to score the severity of the pancreatitis, if this turns out to
be the diagnosis.
Regarding imaging, I would order an urgent erect CXR to look for air under the diaphragm, but also to exclude
a pneumonia. Depending on my examination findings, I would consider an abdominal radiograph to look for
dilated bowel loops or stones.
Further, specialised test might include a FAST scan, to look for free fluid within the abdomen, or indeed a formal
ultrasound assessing the biliary tree and pancreas. I would consider a CT KUB for renal stones, or with
pancreatic protocol to look for pancreatitis.

Advice

It might seem odd to structure your investigations - but again, it gives you a fall-back if your mind
goes blank. It also demonstrates a logical train of thought that the examiners will find appealing.
Never forget an erect CXR in abdominal pain, likewise - a pregnancy test in female patients.

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Clinical Station
Epigastric Pain II
Investigations are as follows:

HR 120, BP 90/60, temp. 37.7, RR 30

Hb 130, WCC 17, CRP 85, urea 17, creatinine 120, amylase 700, bilirubin 23, AST 150, albumin 35

Pa02 9, PaC02 4.1, lactate 3, glucose 7, calcium 1.9

Q. What scoring systems do you know for assessing severity of pancreatitis?

Glasgow, Ranson.

Q. What is this patient's Glasgow score and how did you obtain it?

The patient’s Glasgow score is 4.

The patient scores 1 for each of age > 55, WCC > 15, urea > 16, calcium < 2.

Scoring is as follows (PANCREAS):

• P02 < 8kpa
• Age >55
• Neutrophils (WCC) >15
• Calcium <2 mmol/l
• Renal: Urea >16 mmol/l
• Enzymes: AST>200 IU/l, LDH > 600 IU/l
• Albumin <32 g/dl
• Sugar: Glucose >10mmol/l

Q: What are causes of pancreatitis?:

• Gallstones
• Ethanol
• Trauma
• Steroids
• Mumps and other viruses
• Autoimmune, including SLE
• Scorpion sting
• Hyperlipidaemia
• ERCP
• Drugs (Mnemonic - ‘GET SMASHED’ - think it, but don't say it!)

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Clinical Station
Epigastric Pain II
Advice:

Don't simply reel off the list, specify that the first two are the most common, but that there are
other, rarer causes. You then may mention one of two of the rarer causes, as directed by any clues in the clinical
scenario. Simply going through the list verbatim gives the impression of someone who is at medical school level
and can learn facts, but hasn’t yet learnt to filter what information is important and relevant. In addition it wastes
time, and can lead to unnecessary questions which you don’t know the answers to. One favourite (sadistic)
examiners’ trick is ask candidates who mention scorpion stings, which particular species of scorpion has venom
which causes pancreatitis, then where they can be found, what time of year it is active, whether the male or
female is venomous etc…
By making your answer relevant, you can avoid such pitfalls!

Q: What is the likely cause of the low calcium?

This is most likely caused by fat necrosis occurring as a result of released enzymes leads to the release of
triglycerides. These combine with calcium in a process called saponification, leading to hypocalcaemia.

Q: What eponymous signs may be associated with pancreatitis? Describe them.

Grey-Turner's sign is bruising on the flanks secondary to retroperitoneal haemorrhage tracking from the
pancreatic area.
Cullen's sign is peri-umbilical bruising secondary to pancreatic enzyme tracking to the anterior abdominal wall
and subsequent tissue digestion.

Advice:

Sometimes it’s useful to know a few choice facts about the commonly encountered conditions, because even if
you aren’t asked directly, adding them into your answer looks good, and may also come up in your MRCS
examinations.

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Clinical Station
RTA

You are the surgical SHO on-call and you get a trauma call informing you that a 35 year-old gentleman
involved in a motorcycle road traffic accident travelling at 35 mph will arrive in 10 min.

What would you do?

Prior to the patient arriving I would go to resus in A+E and introduce myself as the surgical SHO on-call. I
would ascertain who the other members of the trauma team are and clarify that I will be leading the trauma call.
Each member of the team would be given a specific role to facilitate timely assessment and resuscitation of the
patient. Each member of the team would wear apron and gloves, and a final equipment check will be
performed.

What would you do once the patient arrives in resus?

I would perform a ‘ABCDE’ primary survey according to ATLS principles. The first step would be to perform
airway maintenance with cervical spine protection. I would ascertain airway patency by talking to the patient
whilst rapidly assessing for signs of airway obstruction.

Informed by the examiner the patient is able to communicate verbally.

As the patient is communicating verbally, the airway is unlikely to be in immediate danger. However, frequent
repeated evaluation of the airway should be performed during the primary survey I would then immobilise the
C-spine with 3-point in line immobilisation using collar, blocks and tape.

I would assess breathing to ensure adequate ventilation and oxygenation. Starting with inspection, I would
carefully expose the neck and chest to assess for equal and bilateral chest expansion, jugular venous distension,
use of accessory muscles and any signs of injury. I would then determine the patient’s respiratory rate. I would
palpate the trachea and chest wall to assess for tracheal deviation and equal chest expansion. I would then
percuss the chest and auscultate the chest bilaterally. During my chest examination, I am actively assessing for
injuries that may severely impair ventilation and require immediate treatment. These include tension
pneumothorax, open pneumothorax, massive haemothorax, flail chest and pulmonary contusion.

Informed by the examiner the patient does not have any of the above injuries.

I would administer high flow oxygen, 15L/min, through a non-rebreathing bag and attach a pulse oximeter to
the patient to ensure adequate oxygen saturation. I would then ask a member of the team to perform an arterial
blood gas. Before moving onto circulation, I would reassess the patient’s airway and breathing.

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Clinical Station
RTA

Informed patient’s airway is patent and nil change in the patient’s breathing status. Patient’s RR is 25 and
saturations 97%.

The next step is circulation with haemorrhage control. I would assess the patient’s skin colour, pulse, and
capillary refill time, and ask for a blood pressure reading.

Informed the patient is tachycardic at 120 with a BP of 110/90, and a CRT of 4 sec.

The patient is currently in at least class II shock. I would insert 2 large bore cannulas into the antecubital fossa
and simultaneously obtain blood for FBC, U&E, LFTs, clotting and G&S, and a venous gas for a lactate level if
an arterial blood gas has not been obtained. I would also cross-match 4 units of blood. I would initiate
intravenous therapy by prescribing a 1L bolus of warmed Hartmann’s solution. I would identify and control any
source of external bleeding by applying direct pressure to the external bleeding site.

Informed no external source.

I would then consider the presence of internal bleeding.

What are the major areas of internal haemorrhage?

The major sites of internal bleeding are the chest, abdomen, retroperitoneum, pelvis and long bones.

The abdomen is slightly distended and tender.

I would then reassess the patient by assessing airway, breathing and circulation.

Informed the patient had a transient response to the initial bolus with nil changes to the patient’s airway and
breathing.

I would prescribe another 1L bolus of warmed Hartmann’s solution and request 1-2 units of type-specific blood
to be transfused to the patient.

What bedside test could be performed in this situation?

A FAST scan can be performed at the bedside as a tool to detect intra-abdominal bleeding.

To complete the primary survey, I would perform a brief neurological examination to assess the patient’s
disability including patient’s GCS, pupil size and reaction, and any lateralizing signs. I would then expose the
patient by completely undressing them but avoiding hypothermia, perform a log roll and a digital rectal exam. If
a urethral injury were not suspected, I would ask for a urinary catheter to be inserted so that the patient’s fluid
status and response can be monitored. I would now reassess the patient by repeating the ABCDE examination.

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Clinical Station
RTA

Would you inform a senior?

Once I have completed the primary survey and initiated resuscitation I would urgently inform my senior registrar
about the patient.

Would you send the patient for a CT scan of the abdomen now?

The patient may need a CT scan in the future but is currently not haemodynamically stable enough to go for a
CT scan. At this stage I felt I was doing well in the interview and had developed a rapport with the examiners. I
ended the question by saying “I do not want to send the patient to the doughnut of death”. The examiners liked
the joke and laughed in response.

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Clinical Station
Post operative assessment

You are the surgical SHO and a nurse calls you about a post-operative patient whose PAR score had
deteriorated.

What%would%you%do?

As the nurse initially called me, I used this opportunity to demonstrate my knowledge and prior use of the SBAR
communication framework. I started by saying I would use the SBAR framework to communicate with the nurse
and learn about the patient’s condition.

What%does%SBAR%stand%for?

It stands for Situation, Background, Assessment, and Response/Recommendation. What is the situation?

The%situation%is%that%a%19%y/o%man,%day=3%post%open%appendicectomy%has%become%unwell.The%
background%is%that%the%patient%was%admitted%4%days%ago%with%RIF%pain.%He%underwent%an%open%
appendicectomy%the%next%day.%%

Any PMH or previous surgery?

He%has%no%previous%PMH.

Assessment?

On%assessment%he%is%tachypnoeic%with%a%respiratory%rate%of%24,%tachycardic%with%a%HR%of%122%and%has%a%
temperature%of%38.9°C.%What%is%your%response/recommendation?%%

Does the patient have any allergies?

No

Can you please start some intravenous paracetamol and IL of Hartmann’s solution? I am on my way to assess the
patient.
Once I am on the ward, I would assess the patient using the CCrISP system of assessment. Immediate
management would be an ABCDE assessment of the patient. I would initially assess airway patency by asking the
patient ‘How are you?’. An adequate response would inform me the patient’s airway is currently patent.

The%patient%is%talking%

I would then administer high flow oxygen, 15L/min through a non-rebreathing bag and assess the patient’s
breathing by inspecting, palpating, percussing and auscultating the patient’s chest. I would determine the patient’s
respiratory rate and ask the nurse to attach a pulse oximeter to calculate the patient’s oxygen saturation. Is there
anything wrong with the patient’s chest?

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Clinical Station
Post operative assessment

Apart%from%a%RR%of%24,%patient’s%breathing%is%normal%with%nil%acute%Tindings%

I would then assess the patient’s circulation and perfusion by palpating both central and peripheral pulses and
determining capillary refill time.

The patient has a bounding%pulse%with%a%HR%of%120%and%CRT<2sec.%Their%temperature%is%38.9°C%

I would secure at least 1 large cannula, minimum 18G calibre, and take blood cultures, a full set of bloods
including FBC, CRP, U&E, LFTs and clotting, and a VBG for a lactate. I would then ask the nurse to administer
1L Hartmann’s STAT and intravenous antibiotics as part of the sepsis 6 bundle.

What%is%included%in%the%sepsis%6%bundle?

The sepsis 6 bundle includes high flow oxygen, blood cultures and a full set of bloods, intravenous antibiotics,
intravenous fluids, lactate and monitoring urine output. I would then determine the patient’s neurological status
and expose the patient. During this part, I would carefully examine the patient’s abdomen by inspecting the
wound site for any infection or discharge. I would assess for abdominal distension and palpate the abdomen to
assess for any tenderness or peritonism.

Patient%has%severe%tenderness%around%the%wound%site%and%right%side%of%the%abdomen%with%signs%of%
local%peritonism.%%%

Once I have completed my initial assessment I would re-assess the patient to ensure my resuscitation measures
have improved the patient’s condition or to identify further deterioration and need for immediate senior help.
At this stage, if the patient were stable, I would perform a full patient assessment. This would include reviewing
the patient’s observation chart, drug chart, blood test results and operative notes.

What%would%you%look%at%in%the%patient’s%operative%notes?

I would look at the patient anaesthetic chart to see if there were any peri-operative issues, the medication
administered peri-operatively and the surgeon’s operative notes. I would look at the operative finding’s to see if
any signs of infection was noted and it so whether it was contained or spread through out the site/abdomen. The
findings would help classify the surgical procedure as clean-contaminated, contaminated or dirty.

Would%you%inform%your%senior?

I would inform my senior registrar early as the patient may require imaging in the form of an ultrasound scan or
CT abdomen and pelvis, and further surgical intervention.

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THE INTERVIEW

PORTFOLIO

PORTFOLIO STATION through the answers you gave in marks. A well structured and
Introduction the application form, through organised portfolio allows the
assessment of your portfolio and interviewer to quickly find the
through your answers to the relevant information. We provide
Your portfolio is a key piece of
interviewers questions. Compared a guide to the portfolio below,
the interview process. It is like an
to previous years there is now a which you should take time to
extended CV, a chance to
much heavier focus on the drop review. Candidates who attend
demonstrate your achievements
down questions from your our interview course will get the
during your medical school,
application. Essentially the chance to see how the portfolios
foundation years and beyond.
interview is tasked with assessing of the top ranking candidates
Surgical applications at CT1 level
the evidence you have to back up f r o m p r e v i o u s ye a r s w e r e
are increasingly competitive and those achievements. structured, and have their
you will be competing against portfolio personally assessed by
your peers who will have similar Before the start of the interview, the same candidates. There’s
aims. portfolios are collected so that the always room for improvement, so
Your portfolio station is worth interviewers can mark them if you don’t get a place on the
33.3% of the total marks for your against a standardised scoring course, make sure that you show
interview as a whole. In 2015 a sheet. This mark combined with a your portfolio to a senior surgeon,
pilot leadership skills presentation score generated from your and to a good trainee who has
was run. This is expected to be portfolio and your answers to the recently been through the
formally included in 2016. Its a questions in the station give a interview.
great opportunity to showcase total score.
yourself - as long as you are The questions asked during your
The job of the interviewer is a portfolio station are designed to
properly prepared.
difficult one as they have a very allow you to show the interviewers
The role of the portfolio station is limited amount of time to go the evidence they might not have
to assess your achievements to through your portfolio and your found themselves.
date. Assessment is threefold; task is to help them give you the

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Portfolio Station
Introduction

In 2015 a leadership presentation pilot was run. Each applicant was required to present a pre-prepared (non
powerpoint) 2 minute leadership biography This was followed by 3 minutes of questioning by the panel. In 2016
it is expected (at the time this went to press) that this pilot would become a formal part of the station for 2016.

It is essential that you know your portfolio well and can turn to the relevant section quickly. During the course,
you should be prepared to do this under pressure during both the small group sessions, and the mock interviews.

Here’s one candidates experience of the portfolio station last year.

“During my interview, there were 2 very friendly interviewers which helped calm my nerves. They had already
gone through my portfolio and marked some components on their marking sheet. One of the first questions they
asked me was ‘’I see you have attended a number of courses such as the BSS, ALS and ATLS which are very
good but why have you not done the CCrISP course?’’. Not really a question I was expecting so I have not
rehearsed an answer for this. I answered truthfully and explained how I did try to attend the course however was
let down by many institutions as core surgical trainees were given priority to attend the course:

‘’I understand the CCrISP course is a very useful course to attend for surgical trainees as it trains trainees on how
to deal with sick surgical patients efficiently which is an essential skill to have. Hence I contacted many
institutions to book a place for myself on the course however at most I was put on the waiting list as priorities
were given to core surgical trainees and I was a foundation trainee when I applied. Places were also very limited
on the CCrISP course. Although I did not manage to get myself onto the course, I have borrowed the CCrISP
manual from the hospital library which I have found very useful. I also plan on attending the course as soon as I
start my training as a core surgical trainee.’’

The interviewers responded in a very understanding manner. They said that this is a very common problem
faced by foundation doctors who are interested in attending the CCrISP course and that the college should think
of a way to overcome this. I was then asked:

‘’You have many done audits and presentations which are good. But how and what do you think you could
improve in your CV?’’

At that particular moment, as a foundation year 2 trainee who has just recently figured out what I would like to
do for the rest of my life i.e. surgery, I could think of a million ways of how to improve my CV.

I thought about the question for a while and decided to answer this question in a similar way I would talk
through my CV which is in order of the mnemonic CAMP (clinical, academic, management, personal) but
modifying my answer to suit the question at hand:

‘’There are many ways I can improve my CV. As a trainee pursuing surgery, clinically, I will try my best to spend
more time in the operating theatre to gain more experience and increase the number of my logbook entries. At
the same time I will ensure that my clinical duties in the ward are not compromised and that there is adequate
cover while I am in theatre. I will also get as many work-based assessments completed as possible with

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Portfolio Station
Introduction

constructive feedback from my assessors so that I am able to reflect on my clinical practice and ensure
progression.

I also plan on expanding my academic interest. Although I have been involved in teaching medical students a few
times, I would like to be more involved in regular formal teachings for junior doctors as well and journal club
meetings as this not only helps me consolidate my own learning but also helps my colleagues and I keep ourselves
up to date with the advancements in surgery.

I have previously led audit projects and completed four audits however I have yet to complete an audit cycle. This
is something I am very keen to pursue as I will be able to make a bigger contribution to my department with a
completed audit cycle which results will give a better indication on how to improve current clinical practice.

Personally, I will ensure I continue to be supportive and understanding with my colleagues and other healthcare
professionals at work as I would like to continue having good feedback on my multi-source feedback assessments
and hopefully even more encouraging and positive feedback. Out of medicine, I would like to continue with my
diving activities and obtain an advanced diver license. These are a number of ways that I have planned to both
improve my CV and help with my professional and personal progression. I will outline my objectives in the
coming year with my educational supervisor and layout a clear course of action to achieve these.’’

I was then asked to talk about my research experience so I talked through my research experience both as a
medical student and the 2 research projects I was involved in during my foundation training. I described each
research project briefly and outlined my role in these projects. I also elaborated on the research-related and
general skills I learnt, the outcomes and the presentations from these projects. On top of that, I included the
journal club meetings I attended, papers I have presented during these meetings and expanded further on the
critical appraisal course I attended.

This was followed by question on which surgical field I would like to pursue my career in. I did not commit
myself to one field for this question as this was true. I explained that I was interested in both ENT and
Neurosurgery as a career, explained how I developed my interest and gave the pros and cons of both fields. I also
pointed out the evidence I have in my portfolio as proof that I have taken steps to further my experience in both
surgical specialties which I think helped me to answer the question a lot as it reminded me of what I have in
portfolio to expand my answer. It is possible that I was asked this question as my CV especially during my
foundation years were mainly ENT- and neurosurgery-oriented. I also used this chance to point out why core
surgical training would be ideal for me as I would be given more time and experience both surgical specialties.”

7 top tips from previous candidates

When preparing for the station, it is a good idea to look through your portfolio and write a list of possible
questions you may be asked on what you have and do not have in your CV. Know everything in your portfolio.
Interviewers can select anything to discuss. For example, if you have not done any teaching previously, it may be
possible you get asked why you were not involved in teaching. During the Core surgical interview course we will

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Portfolio Station
Introduction

show you how to organise your portfolio in a way that helps to direct the interviewer towards the achievements
you want to speak about, rather than to that tiny audit you did 2 years ago that if difficult to discuss.

Have a system on how to answer various questions so that even if you are asked a question you have not
practiced before you still have something to refer back to. Several techniques are mentioned in the guide and
we’ll put you through your paces, in the fun, but high pressured environment of the small group sessions.

Practise both the standard questions for interviews and questions personalised to your CV. Prepare for as many
questions as you can. It really helps and makes a difference. We provide a lot more questions than are required
below based on the principle that the more chance you have to practice the better.

Always remain calm! Don’t panic when you are asked a question you did not expect. Stay calm and think of how
you would roughly format your answer systematically. Have a mental image on how you would arrange your
answer in simple bullet points and then expand on these in a structured manner.

Do not rush to answer a question. Take some time to make sure you understand what the question is asking for
and think of how to answer it.

Always smile, appear confident and be friendly. Do not be too confident as this may come across as arrogance
and do not be too rigid and monotonous in your speech. It is a formal interview but the interviewers would like
to know they can enjoy working with you for the next few years.

Enjoy the interview. It is possible. Surprisingly.

We aim to walk you through the worry and the stress associated with the creation of an effective portfolio,
through to the point where you produce a a summary of your work that is clear, coherent and ultimately
impressive.

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Portfolio Station
How to Structure Your Portfolio

Presentation

Presentation of your portfolio can be as daunting as the interview process itself, but it is an excellent way to
review your achievements, and find gaps in your CV which you may still have a chance to fill. It will also get you
thinking about questions items in your portfolio may raise and you can start to formulate answers to these. The
majority of candidates use a simple A4 ring binder with file dividers. This allows your work to be clearly
categorised and helps the panel navigate your portfolio at will. Remember that the panel have to look at
hundreds of these over a few days. Commonly, the portfolio interview panel is made up of three interviewers.
Two will conduct each interview, whilst the third reads the portfolio of the incoming student. An impression of
good presentation skills and organisation are important for any trainee and will get your examiners onside from
the start. Buy a brand new ring binder, of a neutral colour, and some high quality printing paper. Use the paper
for your CV and the key pages you want the panel to flick to at the very least. Investing in good quality dividers
and file pockets is definitely worth it, as you will give the impression that you are serious about your career and
that you really want to get in. WHSmith and Rymans both have a range of these. We recommend buying the
standard “glossy” file pockets in which you put an individual sheet (plus photocopies hidden but accessible behind
it if required) and the “open slip in” file pockets which can be used for things you would like the interviews to
take out and read, such as PDFs of your publications, or your CV.

Contents

Your portfolio should start with a clear page of contents. Whether you use individual pages or sections divided by
plastic folders or section dividers, each section should be clearly numbered.

One of our editors used her CV at the front of her portfolio in lieu of a contents page, so that the panel
immediately had an overview of her achievements. She then reprinted the relevant parts of her CV as a front
page for each ‘chapter’ in her portfolio.

Obviously, the order of the contents will depend on what you have achieved throughout your training.

The following is a suggestion of a possible format for your portfolio:

Formal Documentation

o Curriculum Vitae

o Application form

o References

o Attainment of FY1 competences

o Passport copies and passport photographs

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How to Structure your Portfolio

o MBBS/MBChB

o BSc certification

o MRCS A/B (if applicable)

Prizes and Awards

o Including essay prizes, audit prizes, year-group prizes, presentation prizes

Employment

o Including jobs, hospitals, consultants

Clinical Skills

o Surgical Logbook --> sign up to ISCP now. It shows that you are aware of what is used in core surgical training
(and beyond) and that you are already engaged with the process.

o Basic Surgical Skills

o CCrISP course

o ATLS

o ALS

o Other courses attended (as applicable)

ePortfolio

o Summary of e-portfolio

o FY1 & FY2 DOPS Summary

o FY1 & FY2 Case Based Discussion Summary

o FY1 & FY2 Mini CEX

o FY1 & FY2 Mini PAT Summary

Choose a few of your best work based assessments,; the scores were actually looked at and noted during interviews

o Clinical Encounters – Reflective practice

o Evidence of Attendance at surgical teaching sessions

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How to Structure your Portfolio

Publications

o Summary of your publications including your role in the work

o Colour PDFs in booklet form that is easily accessible (best work first)

Presentations

o Summary of your presentations including your role in the work

o Colour powerpoint presentation (6 slides per page) or PDF of poster (best work first)

Audit

o Summary of your audits including your role in the work

o Colour powerpoint presentation (6 slides per page) or summary sheet of each audit (again best work first)

Teaching

o Evidence of teaching courses attended (eg: Training the Trainers)

o Evidence of teaching sessions given

o Example paper based or electronic feedback (as applicable)

Management and Leadership

o Examples: Foundation School (FY1/FY2) representative

o Mess President

o Involvement in the British Medical Association Junior Doctors Committee or other professional organisation

o Involvement in rota design

Extracurricular

o Sporting achievements

o Charitable pursuits

o Musical interests

o General lifestyle interests (if can be applied to competence in surgical career)

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How to Structure your Portfolio

Formal documentation will include your General Medical Council (full and provisional) registration document
(with 2 copies) and medical school certification (plus any other degree certificates that you may possess) (each with
2 copies).

You will also need to provide 2 original forms of photo ID and one original documentation providing proof of
address OR one original form of photo ID and 2 original documents providing proof of address. This is in
addition to 2 passport photographs with names printed clearly on the back. The attainment of FY1 competences
will come in the form of a completed 5.1 form. This should be signed off by your foundation school at the end of
your FY1 year.

If you have completed your Royal College Membership exams, you should include the original certificate and 2
copies at this stage. It is a good idea to have two photocopies of each certificate in your portfolio in case they ask
for it as evidence.

Overseas graduates will need to include evidence of their undergraduate training in English, as well as an
original (plus two copies) of the English Language Testing Certificate. This is in additional to a current
Immigration Status page (including visa stamp) and supporting documentation from the Home Office (where
applicable).

*In cases where original documentation is outstanding, you will be required to supply originals within 48 hours
(excluding weekends and bank holidays) following your interview between the hours of 9am and 5pm. Failure to
provide the missing documentation within 48 hours (excluding weekends and bank holidays) and in person
would result in your application being withdrawn.*

We have included a more detailed section on all the important categories and what you might be asked about
below.

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Portfolio Station
Curriculum Vitae

Curriculum Vitae

You should include at least three copies of your CV for all members of the interview panel, and make it easy for
them to remove them from your portfolio.

Your CV should include a brief pre-university educational history and then your university qualifications. If you
received any prizes at university for finishing in the top 5% or 10% on a particular firm, or end of year prizes,
include these here, along with the percentage of your year group that attained the particular distinction.

If you graduated from medical school with a Merit, Honours or Distinction, this should be obvious. This is not to
say a double size font with an underline, but it should be clear to the reader that you are not a run-of-the-mill
candidate by placing it in a prominent position.

If you have completed a BSc, BA or BMedSci, include this here, along with your degree classification.

Any further degrees prior to entry to medical school should be clearly mentioned. In the case of further work on
PHD or Masters qualifications, you may want to deal with this separately, especially if your work was substantive
and would have a direct impact on your suitability for surgery. Make sure that you link your education
experiences back to your aptitude, as well as interest in a surgical career.

At FY2 level, your employment history is likely to be fairly generic. You should give your job information starting
from your most recent post and working backwards to the start of FY1. If this is not your first time applying for
CT1, you may have completed an FTSTA job or another lateral non-training surgical post. Instead of trying to
hide this amongst the mass of other things in your CV, use this as a strength! You will have experience that other
trainees will not have had and you should take advantage of this. At your eventual interview, you should
emphasise this additional surgical experience is in itself a proof of commitment to specialty.

Be careful to clarify the relevance of all the experiences mentioned in your CV to a surgical career and do not
downplay your achievements. Keywords like ‘organised’, ‘led’, ‘designed’ and ‘proposed’ are almost universally
preferable to ‘participated’. Be careful however, to show that you are a team player through your featured
experiences. Many surgical candidates are overly keen to always appear to be the alpha-male or female. This
ignores the fact that the vast majority of your career will be spent working as part of a team. Use this to your
benefit when mentioning achievements in sports or music. Emphasis the fact that you have experience of
working with others in a high pressured environment towards a common goal and show how this will make you a
better trainee.

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Portfolio overview

Application Form

It is advised that you include a copy of your application form in a section of your portfolio. Make sure you know
everything you have included in your application intimately. For instance, they often will ask about a particular
audit and then for your actual results. Potential questions such as, “describe your best audit” which was asked last
year, are discussed in a separate section below

Courses

Be sure to include verification of any courses that you have mentioned in your application form. This includes
the main surgical courses, such as ATLS, BSS and CCRISP, but also ALS, communication skills courses, teaching
skills and other courses towards specialist training. Any courses, meetings or conferences that you have attended
however, can be used to show additional commitment to specialty. Make sure you include two photocopies of the
course certificate in each file pocket so that they can take them if necessary.

Be prepared to answer the question “what did you learn from this course?” It has been made clear by the
London Deanery that courses and conferences shouldn’t just be attended to put on your CV, instead you should
always think “what am I bringing back from this course to my hospital/every day work?”

Clinical Skills

Don’t worry if it you do not have hundreds of operations in there, but you should include a logbook, as logging
the cases you do is an important part of being a surgical trainee and they will expect to see it. eLogbook lets you
print out a summary sheet of operations performed which you can include at the front of your logbook, with the
individual operations printed after. At this early stage in your career for the majority of cases you will have
assisted (A) rather than performed. Supervised trainer scrubbed (STS), means that you performed part of the
operation with your consultant or registrar scrubbed to assist you, supervised trainer unscrubbed (STU) means
you were the senior surgeon in the operation and did not need any assistance, but that it would have been
available if you had needed it. Performed (P) is when you are capable, on your own, of performing the operation
and of dealing with potential complications. Your consultant therefore does not need to be available to assist you.
This is where you are aiming when you are a registrar rather than an SHO, so be wary of saying you performed
an operation as the interview panel may well question this, and ask you about critical steps and how you would
deal with complications.

Don’t despair if your logbook is not detailed. The panel are looking for any other evidence that you have an
interest in pursuing a surgical career, not proof that you have vast surgical experience. If you happen to have had
good surgical experience in the past, then highlight this in your portfolio, but the role of core surgical training
and beyond is to deliver quality generic surgical skills.

Prizes and Awards

If you have mentioned prizes or awards in your portfolio, you should include relevant documentation, with

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Portfolio overview

is an extracurricular prize or award, you may be asked the relevance of your award to your future surgical
practice and you should think of some ways in which your award will make you a better team member, better
leader or more effective teacher for example. You may be asked what your greatest achievement is. If so, then
make sure you refer to something impressive in your portfolio if possible, and make it clear why you are proud of
this achievement. It could be a prize, some teaching you did, a presentation, or something outside of medicine.
The marks will focus on why this is your greatest achievement, so it is important to reflect on the effort you put in,
what you learnt from it, and how it is relevant to your future career in surgery.

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ePortfolio

ePortfolio

There are different opinions on the best way to display your eportfolio. I personally opened this section with the
table of contents printed off from the eportfolio website. This allows the interviewers to navigate the eportfolio
section at a glance. You will have a number of case based discussions (CBDs) and mini-CEXs which could be
displayed. You will not have the space to display them all, and the panel will equally not have the time to read
them individually. I got around this by displaying groups and assessments (eg: FY1 CBDs, FY2 CBDs, FY1 mini
CEXs and so on) together. If you are using plastic file dividers, remember that they may not take all the sheets of
paper out of the file so it is a useful tip to front each section with a good assessment, with plenty of qualitative
feedback so this can be easily read by the examiner. I prominently displayed my mini PAT feedback forms and
evidence of reflective practice. Such pieces are more likely to be noticed by the panel as words will always tend to
tell more about a candidate’s manner and clinical knowledge that quantitative data from a CBD, especially if the
assessor has not given any written feedback.

Some trainees have included ‘thank you letters’ or cards from patient’s or patient’s relatives. Whilst this may not
seem altogether important, a satisfied patient is a useful metric against which your clinical verbal and non-verbal
communication can be measured.

Last year people were asked:

Do you think CBD and CEX assessments are useful?

To answer this question well, once again structure is important. One suggestion is to explain why work based
assessments (as they are referred to in CST) are useful to i) the individual, ii) the trainer and iii) the Deanery. We
would encourage you to think around management questions such as this and begin to develop your own
structures to hang your answers on to.
Whatever you truly think about these assessments, it is important to realise their purpose. The deanery is
responsible for training surgeons and has to have a way of monitoring this. One of the most common methods
used through out the UK is a Case Based Discussion (CBD) and Clinical Examination (CEX). Done properly
these are excellent educational tools that allow you to have one on one time with a senior who knows a lot more
about the clinical condition of the patient you are seeing than you do, and receive detailed feedback. The score
reflects how well you are doing, and therefore gives the deanery a method of assessing you without having to set a
formal exam and most importantly, shows that you are improving and progressing. They show that you are
continuing your medical education, and engaging with the syllabus, and also that you are generally well
organised, and able to communicate well enough to get them done.

The interviewers know that many doctors think the assessments are imperfect, so be honest but professional in
your criticisms. For instance, whilst being an excellent tool when done properly, often there is insufficient time to
complete them fully with a consultant. The marks given are not representative of how well you have done, but

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ePortfolio

rather, how generous a marker the consultant is, or how well you get along with them. The interviewers are
looking for an honest balanced answer which demonstrates that you take responsibility for your own medical
education.
It is important to note that different deaneries across the country ask their trainees to complete different numbers
of these throughout the year; look up how many are required by your first choice deanery. They are generally
embraced by CST deaneries; the London Deanery (for example) expects at least 80 work based assessments per
year, with 50% completed by consultants.
This information would suggest to a savvy candidate that they should err on the side of approval of this method
of assessment/monitoring of education and progression. One way of giving a fully developed answer is to say
why they are good, what a criticism of them might be, and how you intend to overcome that problem whilst you are in your
CST years.
A lesson for life - never just go to someone with problems, always bring possible solutions with you.

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2 minute leadership biography

’Please present a 2 minute leadership biography, based on skills you have acquired as a leader and how you
will be able to apply these to core training.’’

Throughout my life I have acquired and exemplified good leadership qualities through the positions I have held.
At school I was appointed as Head Girl, as an undergraduate I captained the University Hockey Team and lead
a charity raising expedition up Mount Kilimanjaro, whilst at a postgraduate level I was appointed Lead Clinical
Teaching Fellow for Homerton Trust.

In the latter, I was extremely successful as a team leader. I took initiative appropriately and identified changes
needed to be made to the teaching programme. I discussed and communicated these changes effectively between
Consultants, fellows and students, negotiating between differences of opinions from various groups. From a
personal point, I was consistently well organised throughout and was described by peers as reliable, flexible and
very approachable. Importantly I was extremely enthusiastic and motivating, exampled by encouraging other
fellows to take on greater roles within the various projects and future roles the following year. I know my own
limits and I sought and listened to my colleagues opinions when outside of these limits. The excellent verbal and
written feedback received from consultants, students and teaching colleagues alike confirms this.

Specifically, whilst leading the climb up Mount Kilimajnaro I had to be positive and motivating at all times. I had
to recognise and utilise the best qualities of each of the individual members to ensure a successful expedition.
I will apply similar qualities to my core surgical training. This could be in the operating theatre where good
communication between the team is paramount, to on the ward where I will be a reliable senior to the junior
colleagues, listening and acting on all their concerns and encouraging them to take on greater responsibilities. I
will be extremely motivated in my work, identify areas of training to be improved and showing initiative in
tackling these problems.

I believe I have acquired all the appropriate skills to be an excellent leader.

Advice

This new station allows you to show off your greatest achievements from your portfolio. It will be followed by 3
minutes of questioning. You might be asked for evidence of leadership skills you haven’t mentioned or to clarify
the evidence for a particular skill. Leaders tend to be articulate and confident in themselves, so make sure you
practice several times beforehand. Get as much feedback as possible, both on the content and on your delivery.
To make it sound as natural as possible split the 2 minutes into three general points plus a concluding remark.
Commit the message you are trying to convey in each section to memory, rather than the words themselves to
avoid looking too rehearsed. We will practice this station extensively during the course.

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Publications, presentations and audit

Publications

In your application form you were asked about publications that are searchable on the PUBMED database. It is a
good idea to include a summary page with each of your publications listed and briefly summaries in
approximately one paragraph. State the publication, the aims, main results and conclusions and your role in the
work. Often putting your name in bold within the authors helps the person reading your portfolio/CV. Include
any work that is submitted or in progress that you may not have put in your application form. You should then
include a colour PDF print out of your published work in your portfolio, ideally in a slip out file pocket so that it
is easily accessible to your interviewers. Put the publication you are most proud of earlier in your portfolio and
describe it in more detail in the summary page to increase the chances that you will be asked about it. If the
panel have a chance to see the piece of work, they may be more liable to spend time discussing it. Make sure that
you know the methods you used and the results, and be prepared to discuss them.

Presentations

Again here, we would recommend that you include a summary sheet summarising all the presentations that you
have done briefly and highlight the role that you played. It serves to draw the interviewers eye where you would
like it to go, and also is an excellent way of reminding yourself of presentations that you did years ago. Include
the actual presentation if you can, normally as a printed colour handout, with 6 slides per sheet. Powerpoint
presentations are normally colourful and therefore make your portfolio look more aesthetically pleasing. Like
above, know your presentations inside out.

Audit

A summary sheet here, with a paragraph on each audit is very helpful as it allows you to highlight the role you
played, which is what they will be interested on finding out.
Include a powerpoint or one page summary of each audit
including what you did, the clinical problem, the standard
used, how data was collected and analysed, with relevant
results. Mention any change you made, and results of any re-
audit. If possible include the data collection sheet and any
implementation such as a new pro forma that you came up
with.
Using the words in the diagram to describe the stages you
were involved with can help clarify your role, and

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Teaching

Teaching

Include any certificates of teaching courses that you have. You should include paper or electronic-based feedback
on your teaching. If you don’t have any feedback, get it now. Get in contact with medical students you have taught
on the ward or given lectures to and ask them to fill out a simple feedback form. When discussing the teaching
you have done, be clear about your role. Use 'I' instead of 'we' and if you have been involved in the inception,
rather than just participation in a teaching course, mention this. Be clear about the difference between a local
and regional teaching programme. It is interesting to note that regional teaching is defined as teaching students
from more than one hospital, and a teaching programme is defined as more than one lecture or session with the
same students. Use these definitions to your advantage; write a formal teaching schedule rather than leaving
valuable bedside teaching as informal/ad hoc. Assessors will be looking for evidence that your teaching had an
lasting impact, both on those receiving your tuition and beyond. If you have produced a manual, perhaps a
guide to your old firm, or other teaching materials, this is evidence of your possession of more developed
teaching methods and should be included in your portfolio.

Your answer is further strengthened if you possess a formal teaching qualification and there are a number of
available courses for doctors looking to gain teaching qualifications. The most well known of these is 'Training
the trainers', which looks to teach novel teaching methods to trainees. There are alternative options based at local
hospitals and regional centres, or online. Completing formal training gives evidence of your interest in teaching
and should improve the effectiveness of your clinical communication skills in general. Whatever teaching you
have done, make sure you have either a certificate or written feedback as the interviewer will expect to see it in
your portfolio. The same is true for anything you have put on your CV or application form. Evidence is essential,
so if you have mentioned achieving Grade 8 in the piano and have mentioned that it has helped developed your
manual skills and dexterity, make sure the documentation is included.

In past years candidates were asked:

What is your experience of teaching?

One candidate’s answer:

"I have always enjoyed teaching. I was professionally employed as an A level tutor during my medical student
years, which allowed me to develop important skills that I have continued to use throughout foundation training,
and have developed them further by taking part in the introduction to teaching course. I helped to set up a 4
month long teaching course for medical students during F1, and led a mock OSCE course within the trust. In
addition, I regularly teach medical student informally on the wards and have received excellent feedback to date"

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Other information

Other Information

Your extracurricular pursuits are valid and should form part of your portfolio. They show that you are a rounded
individual and that you recognise the importance of work life balance. Remember that this all forms part of an
interview process and that your portfolio will be read by the panel. If you have performed at a high sporting level
or achieved an impressive distinction in music or the arts, include evidence of this. This could be a certificate or a
programme from your last performance. Remember that your portfolio should look professional and that the
information that you are presenting will form part of an overall impression of what you will be like as a surgical
trainee and ultimately as a potential future colleague.

Allocate sufficient time to getting your portfolio together, it takes a lot longer than you think. Its probably best to
start by searching for all the certificates, posters and power point presentations that you wish to include, and
seeking out the inevitable missing ones. Next, put the different sections together as we have suggested, using an
old file, but one that will not cause any damage to your documents. Once a section is complete, order it with the
most impressive first. At this stage you can draft a summary sheet for the sections like publications, and a sub
contents page for the others sections. Once your portfolio is starting to look near completion, then take a trip to
WHSmiths or equivalent after calculating what you need and buy the high quality stuff. This portfolio will soon
become your most prized possession, sad but true, more valuable than your laptop, girl/boyfriend combined. You
do not want to lose it. So, keep it somewhere safe, where someone else isn’t going to pick up and drop spill tea on
etc and try to keep it in perfect condition until the big day. Photocopy everything and keep the copies in a
separate place - believe us, once you’ve spent hours tracking everything down, you’ll never want to have to do it
again!

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Commitment to Speciality

Why Surgery?

Surgical training is hard, but rewarding. It commonly will last up 8 years or more and this part of the interview is
designed to ensure that you have fully thought about your choice of a surgical career. All applicants will be keen
to convince the panel of their dedication, but what can you do to set yourself apart from other candidates? Most
of the evidence for this will come from your portfolio and it is essential that you have included all the experiences
which could show your dedication.

When answering this question it is important to both explain why you would like to be a surgeon and why you
are the ideal candidate for surgery:

Why do you want to be a surgeon?

The interviewers are looking for a well structured answer which shows dedication to speciality and motivation for
core training. It is important to give a range of reasons, with a personal example,s of why you enjoy it and why
you are suited to surgery. Your answer should be enthusiastic but focused and unique to you.

Perhaps you enjoy using your hands to make an immediate difference to peoples’ disease, or enjoy making
decisions under pressure. Surgery is fast moving when looking after acutely unwell patients in an emergency
setting, which appeals to many people. It is also allows you to look after chronic disease, where a personal
relationship is built up with your patients.

Whatever the reason you have chosen surgery, it is important to use a personal example, and if possible a
reflection/achievement related to this example. For instance here is John's answer from last year.

"I enjoy the challenge of using the practical skills I have developed, whilst I enjoy watching my consultant
carrying out larger cases, I really love performing skin biopsies myself. I can feel myself becoming more dextrous
each time, and improving my technique in small ways. Whilst this is a simple procedure, it has confirmed my love
of surgery. I enjoy seeing a patient beforehand, and explaining the operation and potential risks before carrying
out the biopsy and reviewing them afterwards. Both patients and my consultant have commented positively on
my clinical manner and on how quickly I am improving technically. I am looking forward to doing this for more
complicated procedures later in my career."

His answer is a good one as the example is generally applicable to core surgical training. It is specific and
personal and is appropriate to his current level, an F2. He also manages to mention a small achievement, a

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Commitment to Speciality

consultant's interviewing him would like to have as their trainee. He comes across as enthusiastic and
knowledgable about the need to care for patients before, during and after surgery.
He makes a strong statement at the end of his answer; “I am looking forward to doing this for more complicated
procedures later in my career." It gives a good impression to make confident statements such as this. Don’t say “if
I get into core surgical training’, say “when I get into core surgical training.”

The rest of his answer can follow a similar format:

• Reason why you want to be a surgeon

• A personal example
• Your reflection on what you / why you like it
• +/- an Achievement which positively reflects on you as a potential surgical trainee

It is a good idea to mention a variety of reasons why you want to be a surgeon. These can be research
opportunities, the fact it is challenging, the interaction with other specialties, being able to interpret images and
then do something about the surgical problem, and using advanced technology to name just a few.

You can end by mentioning the particular subspecialty you are interested in going into, "I hope to develop these
skills and then apply for ENT, a specialty that combines my passion for ...."

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Commitment to Speciality

Where do you see yourself in 10 years time?

“I would certainly hope to have completed my clinical training in 10 years time and have become a consultant.
My hope is to become a vascular surgeon. I worked on a vascular surgery firm in my first foundation year and
made a presentation to a national vascular conference during this time. I enjoy the technical nature of the work,
and enjoyed the variety in the types of operations performed, from the more lengthy and complicated bypass
procedures to the minimally invasive venous procedures, where advances are constantly being made.

I have enjoyed working in large teaching hospitals so far in my career, though I look forward to having
experiences of District General Hospitals during my training. I have an interest in teaching and have organised 2
surgical teaching courses for 3rd year students at Warwick medical school. I feel that working as a consultant at a
teaching hospital would give me more access to current teaching materials and allow me to develop this interest
further.

I have a strong interest in research. This was first developed during my BSc, where I managed to complete a
project on plasmodium falciparum, which I followed through to publication. I published the results of a surgical
audit that I completed in June on surgical complications in orthopaedic surgery and I would certainly hope to
have a breadth of research experience in 10 years time. I am interested in pursuing a PhD over the course of my
specialty training. I have discussed this with a number of my seniors who have completed their own research and
I realise that it can increases one's understanding of a subject and improve your clinical practice. I have
considered the fact that this would lengthen my training, but still think that it would be worthwhile. However, I
do not think that I would want to end up in a purely academic role as I would miss daily patient interaction.

I have played rugby at a high level throughout my school and university years and continue to play for a local
side. I am under no illusion that surgical training can be arduous with long and sometimes irregular hours.
However, I believe that having some work-life balance is essential. I would do my utmost to stay involved with my
rugby team on an occasional basis and as much as my work commitments would allow and would hope that I
would still be running out on the odd Saturday if my knees would allow it!

I was involved in an expedition to Nepal giving medical aid to deprived and remote areas on my medical elective
and am currently involved in raising funds for a charity sending medical supplies to deprived communities in
South Africa. As I become more senior, I would hope that my effectiveness in such charitable pursuits would also
increase.”

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Commitment to Speciality

What approach should be taken in answering these questions?

The difficulty of both of these questions are in their simplicity. They were among the most commonly asked
questions in recent interviews; therefore write an answer for both and learn before your interview. The easy
solution here would be to give a generic answer of for example 'I would like to be a consultant in x specialty
working in Manchester', or ‘I want to be a surgeon as I enjoy practical things’. This would be score a poor mark,
despite answering the question posed.

With this sort of question, it is useful to think of how to structure your answer. Such a wide ranging question
merits a wide ranging answer, but you must be careful that you maintain concentration on structure.

A common structure would be to divide your answer into clinical, academic and personal reasons. Candidates
are often reluctant to discuss personal aspirations in an interview, but of course these considerations will have a
bearing on your progression as a clinician and should be considered, at least briefly.

Clinical

You must show that you are aware that a core training scheme is not a specialty programme, however, at this
point, it would be appropriate to discuss your specialty aspirations, if you have one. This could be backed up by
evidence from your portfolio showing that you had given some thought to building a career focussed in that
particular direction. This could be in the form of papers, presentations or taster weeks for example.

Are there any specialties that you would like to develop? Many specialties are so sub-specialised that you may
want to be an orthopaedic surgeon, but want to have an interest in arthroscopic procedures involving the knee for
example. This sort of detail shows that you have given some though to your potential career path. If you do go
into such details, be sure that you can give adequate reasoning behind your interest if questioned more
thoroughly.

Clearly the eventual preferred destination for most clinicians is a consultant post. Would you like to work in a
large, cosmopolitan environment or a more rural destination, a DGH or teaching hospital. Whilst you may not
have thought this far ahead and your decision may change in future, such considerations show a maturity of
thinking that will set you apart from your peers. Again, make sure you can explain this answer. For example, you
may want to work in a large teaching hospital because of your experience in teaching. If you can show evidence
of a teaching course you have attended or a course you have set up for medical students in your portfolio, this will
strengthen your answer.

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Commitment to Speciality

Academic

Are you interested in research? Would you be wanting to pursue an MD or PhD in future? If so, discuss how you
think this will impact on your career and chosen specialty. Are you currently undertaking an MSC or other
further qualification? What have been your experiences of this so far and how do these experiences affect your
plans for future research involvement?

Do you have an interest in teaching? How do you plan to develop this?

Personal

Would you like to be part of a large or a smaller team? You could discuss your experiences of participating in
different types of team at this stage to show your understanding of the multidisciplinary team, but also of good
communication with seniors and other colleagues.

You could also discuss your extracurricular pursuits. If you are a keen sportsman/woman, would you hope to be
playing rugby, lacrosse or netball in 10 years time. How do you feel this would impact on your surgical career and
are there any changes that you will have to make in the intervening period to ensure a good work life balance?

Would you hope to be participating in any expeditions abroad or volunteer work? Surgery gives a lot of
opportunities abroad and if you would be keen to take advantages of these, you should make this clear. You
could again link this to past experiences on student elective or current volunteer projects. This is an opportunity
to show that you are a well qualified, but also a well rounded individual.

You also need to show good commitment to a surgical career to date. This will include your attendance at
surgical courses, such as the Basic Surgical Skills course, Advanced Trauma Life Support (ATLS), STEP Core,
STEP Foundation courses and START surgery courses. Of these, BSS and ATLS are the most favoured by the
interview panel as they are compulsory during core training, and show that you are ahead of the game already.
Course show an interest in specialty and can differentiate you from less driven candidates.

There are a number of associations for junior surgeons, which can be joined by trainees at foundation level.
These include the Association of Surgeons in Training (ASiT). This was founded in 1976 as a forum for surgical
trainees to discuss training matters and now has over 2,700 members. It arranges several courses, prizes and
awards for surgical trainees throughout the year, as well as an annual two day conference including oral and
poster presentations of delegates work. Membership of such associations goes towards highlighting an interest in

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Commitment to Speciality

Many hospitals will hold surgical teaching sessions during generic foundation year training. If you can include
documented evidence of attendance at such non compulsory sessions, this can show a dedication to higher
learning and educational achievement, both of the utmost importance for surgical trainees. Taster weeks are
another useful way for foundation year doctors to highlight their surgical interest. They can often
be negotiated after discussion with your educational supervisor and involve you joining another specialty of
your choice for a determined period. This will be of most benefit if you request a documentation from the
surgical consultant verifying your voluntary attendance for surgical cases, clinics and MDT meetings. It will not
only show commitment to specialty, but also organisation and good communication skills as on occasion, such
intra-firm transfers can involve delicate negotiation with senior members of both teams.

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Commitment to Speciality

Further example questions from previous years:

What are your plans for improvement over the year ahead?

I hope to develop myself further in several key themes.

Firstly, I wish to develop my clinical skills further - not only in theatre, but also in assessment of the acutely
unwell surgical patient. I will attend relevant courses, such as CCrISP, and use my free time to attend theatre
lists in order to become more familiar with the surgical environment. In particular, I hope to attend a course on
laparoscopic surgery as I feel that it is important to get to grips with this technique early on, given how many
operations may now be performed laparoscopically. I hope to become a proficient surgical assistant, confident
with the basic principles of surgery, so that I may be invited to take on certain procedures mostly
independently; for example, aiming to perform a laparoscopic appendicectomy under supervision by the end of
the year.
Academically, I wish to enhance my surgical knowledge by completing my MRCS exam. I will make time to
study for this and take the most of the learning opportunities afforded to me at work, by both asking my seniors
if they might test my knowledge and also asking for feedback on my practical skills in theatre.
I wish to become more involved in teaching of juniors - having experienced some excellent teaching as a
London trainee so far, I understand its importance. I have developed a poster that is being used in A&E for
teaching purposes, and I hope to organise supporting sessions with foundation trainees in order to develop
myself as a clinical teacher.
On a personal level, I hope to become more confident in my role as a trainee, taking on more decisions
independently and being someone that the juniors feel they can come to for advice and support. I am looking to
enrol on a leadership course to develop my skills further. Outside of medicine, I plan on travelling to South
America this summer, where I hope to spend time trekking. I am excited to learn more about another culture,
which will generate an understanding that can only be beneficial in my career as a surgeon.

Advice:

Look at your portfolio - where are the gaps? How can you fill them? Do a little research into relevant courses
that might help you. Think about how you feel in the surgical environment. Are you perhaps lacking a little
confidence in theatre? Do you find it tricky when a patient becomes acutely unwell? If so, mention that you are
keen to spend more time in theatre, or that you are keen to attend the CCrISP course to develop your skills in
looking after very sick surgical patients. Tailor your answer to your preferred surgical speciality if you have one,
but don't forget that basics are important too. Use a structured approach. Talk confidently and enthusiastically -
the aim here is not to highlight your weaknesses, but to show that you are driven, ambitious and have actually
thought ahead on how to to better yourself.

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Portfolio Station
Commitment to Speciality

Why do you think it is important to keep a portfolio?

I feel there are several reasons for keeping a portfolio. Firstly, it provides hard evidence of what I have achieved
so far in my career. I can not only talk about things I have done - but show you certificates I was awarded for
doing them. Not only can I talk about my skills in theatre and my communication skills - but I can show you
letters of support from consultants, and letters of praise from patients. In essence, it is the proof to support and
illustrate that what I say I have achieved it true.
However, I have also found that keeping a portfolio is important in another way - it enables me to look back
and highlight gaps in my progress. For example, I look might look at my presentation section and feel pleased
with how many I have done, but looking closely I can see that one of my national presentations was related to
sexual health medicine, so I might then endeavour to present a more surgically-orientated project nationally.
In summary, I feel that my portfolio helps me to identify not only what I have achieved so far, but what I have
yet to achieve in the future.

Advice

The best answers discuss more than one perspective - so the obvious answer here is that a portfolio is something
used at interview to prove your worth. But the trick here is in identifying another reason why it might be useful.
Again, draw on specifics from the portfolio (use it as an opportunity to flash a project/national presentation)
and talk enthusiastically.

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Portfolio Station
Commitment to Speciality

Take us through your CV

Tip: it may be helpful to break this down into sections in your mind so that you don’t miss out important
areas and to ensure a well rounded answer.

Clinical
Both as undergraduate and postgraduate, I have been highly committed to a surgical career reflected by my
choice of surgical rotations. I have been able to gain exposure by enthusiastically seeking opportunities available
to me in order to strengthen my surgical experience.

By prioritising tasks I have managed to attend theatre regularly thereby assisting, observing and performing in
over 100 validated operations. My seniors have valued my eagerness to participate in theatre and this has been
facilitated by my attendance to the Basic Surgical Skills Course. As a result, they have been happy to delegate
more responsibility to me and have supervised me performing a wide local excision of vascular lesion, excision
of fibroadenomas, dynamic hip screws as well incision/drainage procedures.

Additionally, I value my on call commitments as they have allowed me to build my confidence and competence
in dealing with acutely ill surgical patients. This is reflected in my CBDs and Mini-CEXs where my seniors have
praised my communication, clinical decision-making and ability to recognise acutely ill patients as well as
requesting senior input appropriately.

My regular attendance to multidisciplinary team meetings has allowed me to gain understanding and develop a
holistic approach to the patient care. I have kept this awareness in mind whilst participating and reviewing
patients in the outpatient clinics.

Academic
As an undergraduate, I have researched extensively in the field of oesophageal cancer which has resulted in a
local presentation and BMedSci degree. Additionally, as a foundation trainee I have led and organised a local
surgical syllabus providing one-to-one teaching to 5th year medical students and more recently I have delivered
regional teaching at St. Georges Hospital. This has been facilitated by my attendance to several courses
including clinical presentation skills, teach the teacher course and management and leadership.

Management
I have also been responsible for completing the WHO checklist during theatre lists and this has increased my
awareness of surgical safety and has motivated me to lead and organise regular theatre list meetings to ensure
an effective patient care pathway.

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Portfolio Station
Commitment to Speciality

Understanding and appreciating the roles of my team at large have allowed me to develop as a holistic and
conscientious practitioner. Furthermore, in my previous rotation I took the initiative to update and edit the
trainees guide to ensure smooth handover as well as inspire a high quality of care amongst future trainees.

Personal
I have been fortunate to have worked under some great mentors and human beings, by observing and reflecting
on their good practices I have tried emulating such attributes into my own development. I believe my
aspirations to pursue my surgical career will be strengthened by successful completion of MRCS Part A and the
ATLS course.

You appear to have a vast number of cases in you log book but have only performed a few, why is this?

I believe the nature of the foundation programme is to ensure exposure to all fields of medicine and surgery in
order to build a solid foundation for junior doctors as well as acknowledge their own limitations. However, my
regular attendance to theatre shows commitment to the specialty as this has been difficult at times given ward
based commitments. Therefore, to be able to perform just several procedures under consultant supervision
during my foundation training is a great achievement for me.

What defines a leader?

A leader is an individual who sets a vision, questions current practices and has the courage to make a change.
They then provide an environment whereby individuals are able to develop. By means of organisation,
planning and appropriate delegation of tasks the vision becomes more apparent and goals can be achieved.

Advice

This question may appear difficult at first, however, breaking it down into more manageable sections can help
you to identify how much you have actually achieved, and any areas which need more thought. It is important
to reflect on all your experiences and remember you probably have done a lot more than you think. It is
worthwhile making a note of your achievements and gaining evidence for these well in advance in order to
place into your CV. If you think that you are lacking certain areas for the portfolio station make your other
achievements stand out. It is also strongly advised to look at the person specification for core surgical training
whilst you are thinking about your answer, this will give you a good idea on how you should communicate your
achievements.

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Portfolio Station
Research and Audit

What are the differences between research and audit?

“Research creates or tests new knowledge, whilst audit tests clinical practice against established standards.
Research asks ‘What is the right thing to do?’, whilst audit asks ‘Are we doing the right thing’ ”

This has been a common question over the years,and it is important to have a clearly thought out answer.

Both improve the quality of care provided by a healthcare service, involve answering a specific question, careful
sampling, questionnaire design and analysis of findings. However, there are some key differences between the
two. Research is a ‘systematic and rigorous investigation of materials undertaken to discover/establish facts or
relationships and to reach conclusions using scientifically sound methods.
Clinical audit is the ‘comparison of current standards of service provision against either local or national
guidelines, highlighting deviation from best practice and maintaining and improving clinical practice’. This table
sets out difference between the two which you can use to embellish your answer.

Research Audit

Creates new knowledge and determines best practice Answers the question ‘Are we following best
practice?’
Based on a ‘null hypothesis’ Measures against a set, predetermined standard
May involve experimentation or novel treatments Usually does not involve deviation from standard
practice
Extensive statistical analysis The norm is simple statistical analysis

Results can be generalised and are therefore Results are usually relevant to the local setting, but
publishable may be publishable in the interest of a wider
audience
Always requires ethical approval Rarely requires ethical approval
Usually large scale and long duration Usually small scale and short duration

What is an audit?

“An audit systematically compares current clinical practice agains an established standard. It consists of several
stages:
• Identification of a clinical problem
• Standard Setting

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Portfolio Station
Research and Audit

There are multiple definitions of clinical audit. Pick a simple one that you can easily remember. It is good to
show your knowledge of the different stages of the audit cycle.

What is your own experience of clinical audit?

This question will clearly depend on what you have done. If you are reading this in the run up to an interview
and have not completed an audit, it is imperative that you complete one before your interview date. Audit is
indispensable in the modern health care, and most foundation trusts insist that you complete at least one a year.

In previous years you got marks for the number and complexity of your audit, however the key to top marks is
the role you played. Saying that you “designed, initiated, lead and presented” an audit, will get you more marks
than just “carried out” an audit, so if possible, make sure you use these terms. Completing the audit cycle and a
resultant significant clinical change will score more points.

It is essential to know your audits inside out. Last year candidates were asked what the standard they used was,
and the specific results. Remember, the interviewers will have your portfolio open in front of them, and
therefore will be able to turn to your audit and ask you very specific questions on it. It is easy to be thrown if
you don’t go over all of your audits carefully before the interview.

Describe your best audit

“I have complete 5 audits, in one I noticed that theatre time was being lost due to absent pre operative
investigations, such as ECG and group and save. I consulted with the senior surgeons in the hospital to define a
local standard for time an operation is delayed, designed a computer database to exact information from the
theatre log and analysed and presented it at the trust wide clinical governance day. I suggested a preoperative
checklist that was approved in the entire trust, and used by all surgical SHOs. A recent re-audit that I carried
out demonstrated an improvement from an average of 25 minute delay to 18 minutes per operation. It is my
best audit as it produced a tangible change in practice on a Trust wide scale.”

You need to emphasise your role, so ideally choose an audit that you have taken a leading role in. If you can
describe involvement in all phases, and discuss a significant impact that your audit had, you should score well.

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Portfolio Station
Paper Critique

How do you Structure a Paper Critique?

Advice

This question may be asked theoretically. Some deaneries provided the candidate with a short review or report to
read and then asked for a critique. It may be useful to practice this with a colleague or a senior before your
interview, however the trend in surgery has been to move away from this type of question. Questions change
from year to year, so we thought it prudent to include a sample question in the guide.

When reviewing a paper, I would concentrate on four broad areas. These are

• Aims
• Methods
• Results
• Discussion

When considering aims, one must consider the central research question. What is the paper looking to establish
and how will this add to the current body of scientific work? The question should be succinct, relevant and based
on a thorough review of current literature.

Methods: Ethical considerations must come first here. Laboratory techniques or patient treatments deviating
from accepted practice must be passed by a local, regional or national ethics committee.

The study design needs close inspection. What design was used and how was the population selected? Was there
any potential bias in patient selection or was it truly random? Was the paper retrospective or prospective and is
this selection valid for the study aim? What was used as a comparative group and is it truly comparative?

Results: How was the data analysed? What methods were used? What is the significance of the statistical
findings? Does the sample size limit the strength of the conclusions that can be drawn, regardless of the
significance of the results? P values of greater than 0.05 are generally not considered to be significant. If the
authors have claimed significance at a less strict threshold, there must be an extremely strong statistical reason for
this.

Are there are funding sources or conflicts of interest that could hint at a potential bias in the study conception

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Portfolio Station
Paper Critique

The presentation of the data must be considered with graphs correctly labelled and easy to comprehend.

Discussion: Are the inferences drawn in accordance with the data? Any conclusions stated by the author need to
be substantiated by the study design, sample size and population and statistical analysis. Has the influence of
design flaws and limitations been considered? Who is the author, where was it published and what is the journal’s
impact factor? Could any results be explained by chance or confounding factors?

Your answer should be completed by a summary statement concerning all of the above. This should be a short
paragraph which gives your assessment of the overall strength of the paper.

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THE INTERVIEW

MANAGEMENT

MANAGEMENT STATION the team and a willingness to ask that it will be the easiest of the
Introduction for help when necessary. three.

We include some questions asked It is important to remember that

The management station is worth
in this interview station in the last the management station holds a
33% of the marks at interview.
two years as a guide to what to third of your marks, and therefore
CT1 will see you take on more expect at your interview panel. does require revision. A good
responsibility and whilst you will answer requires familiarity with
Questions vary geographically the structure of the NHS,
be still very much in the infancy
and over time, but we hope to not complaints procedures, and
of your training, you may
only give you examples of strong ethical principles which you may
encounter more non-clinical
answers to some of these difficult not have had a reason to engage
challenges that you would have
questions, but also to help you with during your ward work in
done earlier in your practice; from
start to think about experiences FY1 and FY2.
ethical considerations, to
that you have had personally that
difficulties with colleagues and
can be used as examples. Think before you answer, patient
involvement in clinical
safety is an important starting
governance. There may be a temptation to point in answering many
exaggerate past experiences or management questions,
In this station, you will score
difficulties to try and say what you remember to say you would ask
highly by again giving confident
want the examiner to hear and to for help from more senior
and structured answers. However,
‘fit’ with the question. Don't. Your members of the team and to
these must be tempered by
answer will be much more structure your answer. These tips
knowledge of the law, pillars of
r e fl e c t i v e , c o h e r e n t a n d are the basis of success in this
medical ethics under which we
thoughtful if it is something that station.
work and must show an awareness
you have actually gone through.
of the limitations of your
capabilities as a junior member of Some people struggle to prepare
for this station and some think
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Management Station
Consultant appears drunk at work

You are a surgical SHO on the ward. Your consultant arrives to start the afternoon ward round. You can smell
alcohol on his breath, he is visibly off balance and he is slurring his words. How do you proceed?

‘This situation would need to be dealt with away from the middle of the ward. I would need to take the
consultant away from the clinical areas to a side-room to deal with the issue. I would need to find out more
about the issue by asking some questions. I would suggest that he go home and would ask a supportive registrar
or consultant to cover his clinical duties’.

Advice

A classic interview question that is often repeated and is a candidate differentiating station, in that those who
have prepared for something like this are able to score near full marks, whereas, those who haven’t considered it
score poorly. When there are only 3 stations, doing well in each is essential.

This clearly would be a difficult situation which would require careful handling. Your answer must highlight the
fact that your first concern would be for patient safety. You could not be sure that the decisions made by a
consultant in this condition would be in the best interests of the patient and you would be failing in your duty of
care if you allowed him to make patient contact.

As an SHO, even at an early stage you may not be in a position to deal with this yourself so it might be best to
enlist the help of a supportive registrar or consultant. If there is anything you can do to resolve the situation then
it is a good idea to take the initiative and do so, for instance, you could suggest that he goes home and that he ask
the registrar to lead the ward round.

If you are unable to resolve the situation the next step to ensure patient care is to escalate. Given the fact that
there is a potential for patient harm here, you would be justified in enlisting the help of a senior consultant, or
the clinical head of the unit. This may be difficult, given the fact that this person may be a friend or close
colleague of your consultant. If you felt unable to contact another consultant within the department, you would
be justified in contacting the clinical director. In the interview they specifically ask for this chain of command -
registrar - consultant - head of department - clinical director - medical director. Once you have senior support
the management will normally be taken out of your hands, but they may ask the next steps you would take.

Whilst your first duty of care is to the patient, you also have a duty of care to your consultant. It is important that
he has the support he needs, these include ensuring his work is covered, that he has people to talk to about the
incident and surrounding alcohol issues. The situation would need to be discussed with your consultant and he

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Management Station
Consultant appears drunk at work

would have to be sent home. All patients previously seen by him would have to be reviewed by another consultant
as the decisions made whilst in this condition would have to be assumed to be unsafe.

You also have a duty of care to the hospital and to yourself in this case. It would be imperative that you clearly
documented all the encounters mentioned above. In this event, i.e. one involving a senior colleague, if you
informed a senior colleague or the clinical director, you would have a duty to ensure that appropriate action had
been taken, even as a junior member of staff.

If you still think that the action taken had been insufficient, you would be justified in escalating to the National
Clinical Assessment service and following that, the General Medical Council (GMC), however you should make
it clear that you would ask senior colleagues in the department for advice before taking such action.

For any question like this a similar approach can be taken:

• Ensure patient safety, always your first priority

• Maintain professionalism by taking the situation away from patients,

• Offer your colleague support

• Find out more and discuss the situation, the initiative and act to resolve it if possible

• If resolution is not possible, then you need to escalate the situation to an appropriate level and discuss with the
MDU.

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Management Station
Conflict Resolution

You are an SHO assisting in an elective minor procedures theatre list, however your consultant would like you to complete
the list as he has an urgent meeting to attend to.

When the consultant leaves, the theatre team are apprehensive about you completing the list and advise they have been
finishing late everyday for the past week and would like to leave on time. What you do?

This scenario highlights a case of patient safety. As a prospective core surgical trainee I hold this with high regard
and from the outset I would reassure the team of my surgical competence for the procedures scheduled on the list
by showing a validated logbook that has been signed by my consultant.
I would then seek to understand why the theatre team are apprehensive about me completing the theatre list and
would be receptive to their opinions.
There may be several reasons why they may be feeling this way including the fact that they have recently been
finishing late for the past week. In this instance, I would empathetic to their concern as I understand that they
may have families to attend to and plans outside the work place and have every right to leave within their
contracted working hours.
However, at the same time I would also advise that patient safety is paramount and that I am willing to continue
with the theatre list in the event that it overran and would arrange for the on-call theatre staff to take over if the
day team wished to leave on time.
This would help ensure that patient care is not affected and patients’ needs are prioritised. Cancelling cases on
the theatre list may tarnish relationships built on trust with one’s patients. This may further lead to patient
dissatisfaction and complaints especially if a patient as been kept nil by mouth and no justifiable explanation is
provided for the cancellation.
Additionally, I would take the initiative to see if there were any other theatre lists running in the adjacent theatres
and speak to the consultants in charge of those list to see if the workload could be shared between theatres.
Overall, as a prospective core surgical trainee, it is essential to emulate characteristics of leadership and
management and to work in collaboration with ones colleagues as these are individuals you will have to work
with on a daily basis. By means of effective communication and being receptive to team members, difficult
situations as above can be resolved without hindering the team spirit and patient care.
Furthermore, with establishment of the European Working Time Directive it is difficult to get opportunities
whereby seniors have confidence in you to complete a theatre list and such opportunities should be sought after
and maximised. I would therefore continue with the theatre list and communicate the above initiatives with the
consultant in charge and advise the theatre team that any further concerns/suggestions can be formally discussed
at the theatre-debriefing meeting.

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Management Station
Dealing with Colleagues

How would you react if one of your registrars refused to treat a patient because they were a known
paedophile?

GMC guidance on this directs that if “carrying out a certain procedure or giving advice about it conflicts with
your religious or moral beliefs, and this conflict could affect the treatment that you would provide, you must
explain this to the patient and tell them that they have the right to see another doctor.’ You must also ensure that
the patient has sufficient information to enable them to exercise that right. If it is not practical for the patient to
see another doctor, you would have a duty to ensure that another suitably qualified colleague was available to
take over the role”

In this situation, you have a duty to the patient and to your colleague. Ask one of the other registrars or
consultants to see the patient. Find out more about your colleague’s views, and discuss them with him if
appropriate. If they had strongly held feelings on a particular issue, these could be related to past personal
experiences or traumatic events. You would have a responsibility ensure they have appropriate support and could
advise a referral to occupational health.

You suspect one of your fellow surgical SHOs is suffering from stress. How would you proceed?

Here there may be a risk to patient, depending on how your colleague is able to manage his stress. If a colleague
can’t carry out their clinical duties due to stress then patient care will suffer. You should discuss it with the
colleague concerned and offer to help them with some of their tasks as long as your own work wont suffer.
Sensitively use examples of when you feel that patient care may have been compromised and make sure it is
understood that your role is supportive, rather than accusatory. Find out what is happening to cause them stress
and if you can suggest solutions such as taking some time off, organising their day differently, changing teams, or
that they take on less work. Suggest that they seek help, either from the consultant involved or from occupational
health. If your colleague refused to seek help, you may have to escalate this to a registrar or consultant if you feel
they cannot carry on working. Make sure your colleague knows that you are planning to do so first as any
inappropriate involvement of a senior team member may cause problems within the team that will be difficult to
remedy.

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Management Station
WHO checklist

The WHO surgical checklist has played a major role in improving surgical outcomes in recent years. What do
you know about it?

It is a checklist designed to improve surgical safety. It identifies three phases of an operation, each of which
corresponds to a specific period. Before the induction of anaesthesia; the ‘sign in’, before the incision of the skin;
‘time out’, before the patient leaves the operating room; the ‘sign out’. In each phase, a checklist coordinator must
confirm that the surgical team has completed the listed task before it proceeds with the operation.

How would you confirm the site of the operation?

I would check the patient name, hospital number and date of birth, comparing it to the consent form, WHO
checklist and patient band. I would check which site and side the patient has been consented for, check for a mark
indicating side on the patient and confirm this with imagine. This would be done by the surgeon, anaesthetist
and scrub nurse.

Who completes the sign out?

Normally the theatre scrub nurse

What device is used for patient warming?

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Management Station
WHO checklist

Supplementary Information

The WHO Surgical Checklist was introduced in 2008. It aims to increase the safety of patients undergoing
surgery. It aims to ensure that all staff are identifiable, and that errors involving patient identity, site/side of
operation and the type of procedure performed are avoided.

Before Anaesthesia

The patient is asked to confirm their identity, the consent form and the site of operation are checked, and the
procedure confirmed. The side of operation must be marked. Patient allergies are checked, the amount of
expected blood loss discussed, and anaesthetic safety check completed.

Time Out

Before the first incision entire team pause and one of the members, normally the surgeon or anaesthetist, will
read out the “time out”. Everyone must introduce themselves stating their name and role. The surgeon and
anaesthetist must then confirm the name of the patient and the procedure taking place, its site and side, and
discuss any anticipated critical events, and equipment needed. Antibiotic prophylaxis, patient warming, VTE
prophylaxis (TEDS and Flowtrons), hair removal and diabetic control are all considered on case by case basis.

Sign out

After the operation, before the patient leaves theatre there is a further check conducted by the scrub nurses. The
instrument, swab and needle counts are checked, any faulty equipment is noted and specimens are appropriately
labelled and sent. The surgeon, anaesthetist and nursing staff then mention key concerns for recovery.

It is estimated that at implementation of the WHO surgical checklist has reduced surgical complications by more
than one third and reduced deaths by almost a half (from 1.5% to 0.8%) according to a study carried out in the
Netherlands. A surgical safety checklist has become the global standard of care.

Advice

When answering a question that is as broad as this it is important to structure your answer well and directly
answer the question. We also advise that you keep your answer brief. This is because the examiner will normally
have a prescribed list of questions for which you score marks. If you are very lucky or very good, and your essay
style response contains the answers to the questions they were going to ask then fantastic, you have aced this
station. If instead you talk for five minutes and only hit two of the five answers they are looking for then you will
have scored a maximum of 40%, regardless of how good your answers are. If instead you are concise in your
response as in the example above, then the examiner can go on to ask you the questions that will score marks.

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Management Station
Risk Stratification

Do you know of any classification system that quantifies the risk of death whilst under anaesthetic?

The most commonly used classification is the ASA (American Society of Anesthesiologists) system which grades
patients from 1(healthy) to 6 (brain dead) and has been validated for use quantifying risk of death under
anaesthetic

Are there any limitations to the ASA?

There are four main limitations to the ASA grading system.

Firstly, there is a grey area between ASA2 and ASA3, namely for patients with a stable disease, which is neither
mild, nor severe, but which is of moderate nature.

Secondly, the classification of patients with 2 or more chronic stable diseases is unclear, especially if they are of
differing severity.

Thirdly, what constitutes a systemic disease can be controversial as technically a recent MI is a local not systemic
disease and therefore doesn't fit into the ASA categories but influences post anaesthetic survival.

And finally, there is no mention of age in the classification, yet this can have an impact on the incidence of
operative mortality.

There are other scoring systems, such as the APACHE II and APGAR score. However, these are more time
consuming than the ASA scoring system

What would be the ASA classification of the following patients?

40 year old female with Diabetes Mellitus – ‘ASA 2’

45 year old male with stable angina – ‘ASA 3’
70 year old female with heart failure – ‘ASA 4’
65 year old male with ruptured thoracic aneurysm – ‘ASA 5E’

Supplementary Information

The ASA grading system was introduced by the American Society of Anesthesiologists to quantify the risk of
mortality during and immediately post anaesthetic. It takes into account the premorbid state of the patient and
general physical status. It was introduced into clinical practice in 1963 with five clinical categories.This was later
expanded to include a further category.

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Management Station
Risk Stratification

ASA 1- A normal healthy patient

ASA 2- A patient with mild systemic disease
ASA 3- A patient with severe systemic disease
ASA 4- A patient with severe systemic disease that is a constant threat to life
ASA 5- A moribund patient who is not expected to survive without the operation
ASA 6- A patient declared to be brain dead whose organs are being removed for donor purposes.

If the patient is an emergency, the physical status classification is followed by an ‘E’, e.g. 3E. Class 5 would
normally be an emergency procedure, hence 5E. An emergency is therefore now defined as existing when delay
in treatment would significantly increase the threat to the patient's life or body part. With this definition, severe
pain due to broken bones, ureteric stone or parturition (giving birth) is not an emergency.

Advice

The candidate here could have mentioned a number of risk stratification systems, however the question is
specifically looking for risk of death under anaesthetic. ASA is one of the simplest stratification systems, the most
commonly used world wide, and the one that all surgeons will have heard of as it is mentioned specifically during
the WHO checklist. The sample answer (above) uses a good technique for answering questions where there are
multiple answers, namely opening with the structure you are about to use, "there are four...". However during
your interview when you are stressed and prone to your mind going blank, you may be better saying "there are
several..." so that you don't reach the third answer and find you have forgotten the fourth. In the final section,
note how when a direct question is asked the candidate does not waffle, and simply states his answer, showing
confidence and calm under pressure, an key attribute in any surgical trainee.

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NCEPOD

What is NCEPOD and how has it impacted on current surgical practice?

NCEPOD stands for the National Confidential Enquiry into Peri-Operative Deaths. It has made suggestions to
improve surgical safety, particularly during emergency surgery. It has for example suggested that operations
should not take place out of hours if they can be avoided. This has changed practice in the UK. Now each
emergency case must be assessed for urgency, and appropriately positioned on the operating list

What are the CEPOD categories and what are they used for?

There are 4 CEPOD categories or codes that characterise an operation’s urgency. They are immediate, urgent,
expedited and elective. It allows the clinicians and managers who are responsible for allocating theatre time to
prioritise accordingly, and to ensure patient’s are operated on within the appropriate time frame. It aims to
ensure that surgeons are only operating out of hours when appropriate

Are there any procedures carried out by non surgeons that are covered?

Yes, coronary angiography for ACS (carried out by cardiologists) is covered.

What category would a ruptured aortic aneurysm fall under and in practice what would happen?

It falls into the urgent category - 1. In practice the patient would be stabilised haemodynamically with fluids and
blood products at the same time as theatre was being prepared. If necessary, the case would be prioritised over
the next elective case if it occurred during the day, breaking into an elective list, otherwise it would be performed
as soon as theatre is ready.

Supplementary advice

NCEPOD began as a report looking specifically at what factors could have contributed to perioperative patient
mortality in 1987, and now covers all surgical specialities. It aims to alert doctors and hospital management to
practices which could be improved. It does not audit individual surgeon’s performance rather focusing on
hospital practice in general. The essential message from the initial report was that patients undergoing surgery,
especially emergency surgery after 9pm were at greater risk of perioperative mortality.

It continues to review practice and cases that cause NCEPOD concern are referred to the Medical Director of
the Trust and the Consultant involved so that appropriate action can be taken.

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NCEPOD

Code Category Description Target Expected Example Typical

time to Location Scenarios Procedures
Theatre
1 Immediate Immediate (A) Next available Ruptured aortic Repair of ruptured
lifesaving or (B) Within operating aneurysm aortic aneurysm
limb or organ- minutes of theatre – Major trauma to Laparotomy/
saving decision to “break-in” to abdomen or thorax thoracotomy for
intervention. operate existing lists if Fracture with major control of
Resuscitation required neurovascular deficit haemorrhage
simultaneous Compartment syndrome Fasciotomy
with surgical Acute myocardial Coronary angioplasty
treatment infraction

2 Urgent Acute onset or Day time Compound fracture Debridement plus

deterioration of Within hours “emergency” Perforated bowel with fixation of fracture
conditions that of decision to list peritonitis Laparotomy for
threaten life, limb operate and or Critical organ or limb perforation
or organ survival; normally once Out-of-hours ischaemia Coronary angioplasty
fixation of resuscitation emergency Acute coronary
fractures; relief completed theatre syndrome
of distressing (including at Perforating eye injuries
symptoms. night)

3 Expedited Stable patient Elective list Tendon and nerve Repair of tendon and
requiring early Within days of which injuries nerve injuries
intervention for a decision to has “spare” Stable & non-septic Excision of tumour
condition that is operate capacity patients for wide range with potential to
not an immediate or of surgical procedures bleed or obstruct
threat to life, limb Day time Retinal detachment Coronary angioplasty
or organ survival “emergency”
list
(not at night)

4 Elective Surgical Planned Elective Encompasses all Elective AAA repair

procedure theatre list conditions not classified Laparoscopic
planned or booked & as immediate, urgent or cholecystectomy
booked in planned expedited. Varicose vein surgery
advance of prior to Joint replacement
routine admission admission Coronary angioplasty
to hospital

Advice

Do not learn all the categories by heart, but know what each means and the type of case that fits into each. Go
on call with your SPR, to see how CEPOD works in practice.

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Sterilisation

What is the difference between sterilisation, disinfection and cleaning?

Sterilisation is the eradication of all organisms including bacterial spores and viruses
Disinfection is the eradication of most microorganisms; bacterial spores and some viruses may survive.
Cleaning is the physical removal of obvious dirt and contamination without eradication of any organisms.

How may surgical instruments be sterilised?

There are several methods used:

Heat can be used, for instance; autoclaving, which uses pressurised steam at a temperature of 134°C for 3-10
minutes or 121°C for 15-30 minutes, is typically used for trays of surgical instruments. Dry heat, where
instruments are kept at 160 degrees for 2 hours, and is only suitable for instruments that can withstand this, is
used for non aqueous liquids. Chemical sterilisation, with chemicals such as formaldehyde, a liquid sterilisation
agent, is used for plastics and ethylene oxide a colourless gas, used for sutures. Gamma irradiation can be used for
catheters and syringes.

Which agents are used to disinfect skin?

• Alcohol, chlorhexidine and iodine are common skin disinfectants.

• Alcohol is effective against gram positive and negative bacteria, but not against fungi or spores.
• Chlorhexidine is effective against bacteria including Staphlococcus aureus.
• Iodine is effective against fungi, bacteria, viruses and spores.

Advice

A simple question that threw many people as they weren’t expecting it. reading around the practice of surgery,
for instance knowing what instruments are, and what they do may come up, although they are asking this less
frequently than previously.

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Decision making

What is the most difficult decision you have had to make?

The most difficult decision I’ve ever had to make was giving up my career as an accountant to study medicine. I
weighed up the benefits of staying in my job where I had a good salary and security with my keen desire to study
medicine. I consulted some friends who were doctors and found out what they thought, spending a week
shadowing them at work to see if I would enjoy the clinical side more than my current desk job. I spoke to my
partner, and went through the potential financial and social implications, and decided that I had to choose to
study medicine as it had and remains a life long dream to be a doctor

Advice

This is a hard question to answer. It was asked at the London interviews in 2010 and 2011. As an SHO the
clinical decisions that you have to make are relatively simple, and often your seniors will help make it for you. You
may find non clinical answers from other aspects of your life, or find something you have done on the ward
suitable. Make it personal, but brief as you should focus on how you made that decision rather than on
explaining the example in detail. Thinking about this before your interview is essential, otherwise you may be
stuck wasting time coming up with a difficult decision, and not talking about how you made it. The example
doesn’t really matter as long as it is a decision, i.e you could have chosen one of two or more options. If the
choice is obvious then the example is a bad one. The marks are for how you approached the decision making
process.

Other Examples:

• Moving to the South Coast for my Foundation job away from by base in the North
• Breaking up with a partner (be careful to stay professional!)
• Whether to start tinzaparin in a patient with a metallic heart valve who had a cerebral haemorrhage
• Applying to this deanery

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Rota Dispute

The rota is published and you are working every bank holiday and more on calls than your colleagues, what
would you do?

Normally one of your colleagues will be coordinating the rota. It is important to speak to them early, and discuss
this issue. It may have been an oversight, and one they are happy to rectify. It can be useful to approach them
with solutions, not just problems. Emphasise that you would not make any complaints or comments personal. If
they don’t help then you should discuss with some of your other colleagues, to see if any of them can help out,
and swap on calls to make the rota fairer. The next step is to contact Medical Human resources who will
hopefully be able to suggest a solution. Make it clear that it is important that the on calls are covered but that you
would like it to be done fairly. You may need to escalate the issue to a consultant, but make sure you have taken
the initiative to solve the problem yourself first

“I would start by making sure that I was indeed correct in thinking that the rota was unjust. I would look over the
schedule again and ask a friend to review the rota also, making sure that they understood that this was in
confidence. If there was only a slight discrepancy in the rota, for instance in a situation where someone would
have to work one more weekend than others for example because of the number of weeks or months covered,
then I would consider working the shift in question. However, if I felt that the rota was grossly unfair, I would
look to contact the member of staff/colleague responsible for arranging the rota. I would speak to them with
discretion, alerting them to where I felt the unfairness arose. If it was a simple oversight, which they were happy
to rectify, then I would not escalate the situation any further and would not let this error affect my future
relationship with the colleague. If they were not happy to rectify this, then I would discuss the situation with my
other colleagues to see whether we would be able to reach a fairer agreement between ourselves. If this was not
successful, I would look to escalate the issue to Human resources. They would perhaps be able to find a solution.
My concerns would be magnified if the error meant that I was working more than the prescribed maximum
number of hours allowed by the European Working Time Directive”

This may seem like a straightforward question and so it may be easy to give an answer quickly without any real
thought. The first issue here is clarification that there actually is a problem. A large proportion of grievances in
the workplace actually stem from oversight and misunderstanding, rather than true malice or intentional
injustice. It would be wise in this situation, to firstly take a step back and to ask a neutral opinion on the issue.
The issue of patient safety here is key and should be considered in an effective answer. If there are concerns
about your effectiveness to work as a result of this rota error, that can impact on patient safety. This must be of
utmost importance in your mind and in the answer. Any conversation with your colleague must be had in private,
rather than on the ward and should be handled in a non-confrontational manner. This question looks to test
whether you have the clinical communication skills to be able to deal with a challenging situation effectively.

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Rota Dispute

to you in terms of escalation and who would be most effective. If you are going to a consultant or another senior
member of staff, it is essential that you have thought of a solution, (e.g. splitting the excess on-call shifts with
other colleagues) rather than just a problem. The panel will want to see that you are an independent thinker and
have the capacity to problem solve. This should hopefully translate into your clinical practice. The worst answers
here will be confrontational, or at the other end of the scale, overly passive. If you are scheduled to work 7
weekends in a row and you meekly comply with this, you may be avoiding confrontation, but you will also be
tired and likely provide substandard care.

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Data Protection

You are the CT1 for a general surgical firm. You walk into your consultant's office to find his secretary viewing a
CT scan on the computer - her sister is a patient under another team at the hospital and the CT shows
metastatic colorectal cancer, the results of which you are aware have not yet been communicated to the
patient.

What do you do?

I would initially seek to clarify the situation by asking the secretary to talk with me somewhere private. I would
endeavour to find out what exactly she had read, and why, in order to ensure that I had not misread the situation.
However, should the situation be as first appeared, I would want to ensure that the patient's rights were respected.
It would be a difficult situation, because of the lack of time to prepare my approach and the emotions likely to be
surrounding the news, but I would explain, in a non-judgemental manner, that the information was confidential
and that it was not appropriate to view the scan in this way. The news is likely to be distressing for the secretary
and so I would want to show empathy, and reassure her that I would be talking to the consultant and that we
would endeavour to have a family discussion if the patient were willing.
I would escalate the matter by notifying both my consultant and the patient's consultant of what had happened,
in order that a discussion could be held with the patient informing her of the results in a timely, but appropriate
manner. I would explain that I felt she should know that her sister was aware of the results.
I would try to find out how the secretary had come to view the scan. For example - if the consultant had left the
CT scan up on his screen, or the image-viewing system logged on, then this is a confidentiality issue that would
need to be addressed. I would feel anxious about this, because obviously it can be hard to bring up an error that a
senior may have made - but I would be able to do it by reassuring myself that it was in the best interests of the
patient.
At all times I would be sensitive to the fact that this is likely to be devastating news for patient and family alike,
and so would treat the information with respect and ensure that the individuals were offered the appropriate
support.
I would use this a reminder of the importance of protecting patient confidentiality, endeavouring not to leave
patient-identifiable information where it can be viewed easily by others.

Advice

Try to picture the scene with scenarios like this, then you can summon up genuine empathy for what someone
might feel like in this situation. Talk about how it would make you feel, and why, as well as what you would do.
Uses a structured approach ensuring that you cover the need to gather information about the situation and
others’ involvement, ensure patient safety, escalate where appropriate, and consider the support that those
involved, and yourself, may need.

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Data Protection

What is the Data Protection Act?

The Data Protection Act is an extremely useful piece of legislation produced in 1988, which contains rules
governing the protection of an individual's personal information.
The main principles can be divided into two main areas. Firstly - the way in which information is stored: it must
not be kept for longer than is necessary, and while being stored it must be kept secure - for example, use of an
encrypted USB stick when being transferred. In addition, it must not be transferred outside of the UK adequate
protection. Secondly - how the information is used.
The information must be relevant, accurate and not excessive. It must be used fairly and lawfully.
In addition, the Data Protection Act allows individuals to access their information, provided the request is made
in the correct way. This includes being specific about the information required, and the request being in writing.
However, there are situations when organisations may be able to withhold information, such as when it relates to
criminal proceedings.
The Data Protection Act is extremely important in medicine. Patients trust us with extremely personal
information, and so we must endeavour to protect it and maintain this trust. The data protection principles
enable us to do this. In addition, in an era of increasingly evidence-based practice, access to patient information
is crucial for research and development. Therefore, it is imperative that we handle the information correctly.

Advice

Questions like this can be tricky, because you either have heard of the act, or you haven’t. Make sure that you
have! Think about the introductory lectures you have on data protection, information governance etc. and
commit these to memory. Worst comes to the worst and you haven't heard of the act - talk around the subject.
You know that confidentiality is important, so talk about how you enforce it every day. (Do you collect patient lists
at the end of every MDT and shred them? Do you always log off the computer?). Showing that you can apply
the principles is much more important that saying what year the legislation was passed.

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Nurse Practitioners

What is your opinion on nurse practitioners and their role?

Nurse practitioners are taking an increasing role in surgical care. If you have any experience of working with a
good one you will know that for a junior trainee their experience can be very helpful. When you first start a job,
having a nurse who has been there for a long time helps you settle into your job and provides much needed
continuity of care for the patients. Nurses may co-ordinate the administrative side of an MDT and make sure
that patients are not lost to follow up. If done well, they play a distinct but interlinked role in parallel to the
surgical team which provides a more efficient service. A BMJ systematic review concluded that, “Nurse
practitioners can provide care that leads to increased patient satisfaction and similar health outcomes when
compared with care from a doctor. Nurse practitioners seem to provide a quality of care that is at least as good,
and in some ways better, than doctors”

On the other hand, some trainees have found that their training is vastly reduced as a result. For instance, nurse
endoscopists often run the colonoscopy list which previously would have been carried out by the colorectal SpR.
Clinical problems arise when a complication occurs that the nurse cannot deal with, for instance a bowel
perforation during colonoscopy. In this instance it is left to the surgical registrar to manage the complication of a
patient they feel they should have been scoping themselves.

Whatever your opinion or experience, it is essential in any question asking for an opinion to give a balanced
answer, with a conclusion that avoids sitting on the fence. For instance, “I think the role of nurse practitioners is
in supporting patients in a more holistic way than doctors might have time for is a good idea. It is important that
they work well with the doctors, and that the roles do not overlap too much as this can interfere with training
which would have serious implications for the next generation of consultants”

Advice

You may have limited experience of nurse practitioners. They are advanced practice registered nurses who have
usually completed a graduate level of education and expanded their skill set beyond that which would be required of a
registered nurse. What this means in practice is that often, they will know more than the new FY1, FY2 or even CT1
about the current management of a condition within their speciality. In some cases, this can lead to conflict, with
doctors feeling that a nurse is questioning their decisions, or somehow challenging their perceived authority. This
shows a misunderstanding of the way that modern medicine is supposed to work. The oft quoted concept of the
‘multidisciplinary team’ entails a recognition of the skills of others around you and whilst a clinician may well continue
to lead the team, the views of others should be taken into account. This question is strong in that it uses personal
experience to answer the question. It is not unreasonable to mention character flaws that you have had to resolve or
challenges that you have faced in the past. This shows a good level of self awareness and reflective practice, both key
features of being a safe and competent surgeon.

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European Working Time Directive

How will you cope with the restrictions of the EWTD? How will you ensure you get training?

The EWTD came into full effect in 2009. It restricts doctors to working only 48 hours per week, with a minimum
amount of rest and a maximum number of consecutive hours worked. It has had serous implications for surgical
training, as reducing the amount of time at work without reducing service commitments has meant less time for
training opportunities. In practice most surgical trainees simply ignore EWTD rather than miss out on training,
however, you are at interview, making this difficult to say.

Less time training may mean less experienced consultants in the future, resulting in poorer quality of care.
Hospitals have had to compensate with shift pattern rotas,, meaning that SHOs in particular are often on nights,
or on compensatory ‘zero days’ and are rarely on the wards looking after the same patients for an extended
period of time. This reduces continuity of care. You may feel less responsibility when you are busy on call and
are asked to see a well but concerned ward patient who wants to talk to you than if you are regularly there and
therefore know that patient, impacting on the patient experience. In addition it has financial implications as
banding of more than 50% no longer exists, and has therefore reduced junior doctors pay significantly.

The advantages include better rested doctors providing safer care, and indeed a better work life balance for
doctors.

To answer this question well, you need to appreciate the importance of working within EWTD, a legal
requirement, whilst at the same time maximising training opportunities. Be clear that your priority is patient care
and your own medical education, and that you do not feel it is unreasonable to stay late to go to theatre, or to go
in on days off as long as you are not too tired to work when required. Explain that you intend to be organised
and identify the training available early in each rotation by talking to your consultant. You will set out the targets
for training, such as go to theatre and ‘scrubbing in’ in on a whole list twice a week. Decide on the best lists and
clinics to go to with your consultant and get them on board early so that it is an expectation that you will be there
rather than on the wards, or indeed at home on a random off day. If you are asked what you would do if the
wards keep bleeping you because no one else is available to do a TTO then we recommend you stress that patient
care comes first and that you will find time in between cases or patients in clinic to come do the TTO. If it is an
unwell patient then, obviously you need to attend them, but should discuss this with your consultant so that
service cover can be arranged perhaps with another trainee, so that you both can take full advantage of training.

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Incidence and Prevalence

What do you understand by the terms incidence and prevalence? What is the relationship between the two?

Incidence and prevalence both measure disease frequency. Incidence measures the number of new cases in a
specified time period in a specified population. Prevalence is a measure of all the cases in a population at a given
point of time.

Using diabetes as an example, if there were 250 cases of diabetes in a population of 10000 and 10 new cases per
per year, the incidence is 10/10000 per yr, and the prevalence 250/10000. Disease with rapid onset and short
duration, such as acute pancreatitis or cholecystitis have a low prevalence and high incidence, whereas diseases
which are chronic, such as diabetes or ulcerative colitis have a comparatively low incidence and high prevalence.
Prevalence is dependent on the duration of the disease and on the incidence of the disease. It can be
approximated to the product of a disease incidence and its mean duration.

What is meant by the terms sensitivity and specificity?

Sensitivity is the probability of testing positive when a disease is truly present

Specificity is the probability of a test screening negative if the disease is truly absent

Advice

This is a very common question - have a succinct answer ready.

Remember, If 100 patients known to have a disease were tested, and 60 test positive, then the test has a sensitivity
of 60% . If 100 patients with no disease are tested and 90 return a negative result, then the test has 90%
specificity.

You could also be asked about positive and negative predictive value, so here are some easy to regurgitate
definitions.

Positive predictive value is the proportion of subjects with positive test results who are correctly diagnosed as
having the disease

Negative predictive value is the proportion of subjects with negative test result who are correctly diagnosed as
not having the disease

The question has previously been asked in conjunction with the screening question below:

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Screening

What is screening?

Screening is a strategy used to identify disease or pre-disease in currently asymptomatic individuals. It is an

attempt to to identify disease in a population early, to allow earlier intervention, at a stage when the disease can
be treated.

What makes a good screening programme?

The World Health Organisation Principles of Screening suggests that:

• The condition should be an important health problem.
• There should be a treatment for the condition.
• Facilities for diagnosis and treatment should be available.
• There should be a latent stage of the disease.
• There should be a test or examination for the condition.
• The test should be acceptable to the population.
• The natural history of the disease should be adequately understood.
• There should be an agreed policy on whom to treat
• The total cost of finding a case should be economically balanced in relation to medical expenditure as a whole.
• Case-finding should be a continuous process, not just a "once and for all" project.

Are there any criticisms of screening?

Problems include the huge cost involved, and the use of NHS resources on people without disease or need for
treatment. False positive results (test is positive in someone without the disease) induce needless further tests and
worry in people, whilst false negative (a negative result is given for people with the condition) miss the disease and
falsely reassure. A screening procedure may be unpleasant or uncomfortable, for instance colonoscopy for colonic
carcinoma. Overdiagnosis can be a problem. In prostate cancer, it has been suggested that screening diagnoses
malignancy in many patients who would have died with, rather than from prostate cancer.
It is subject to bias; for instance lead time bias. In some cases where screening leads to an earlier diagnosis, but no
prolongation of actual lifespan, screening simply introduces a longer period of worry into the life of a patient
and their family, whilst giving no prognostic benefit. Length time bias: slower-growing tumours have a better
prognosis than tumours with high growth rates, but screening is more likely to detect slower-growing tumours,
due to a longer preclinical period. Therefore screening may tend to detect cancers that would not have killed the
patient or even been detected prior to death from other causes. A selection bias may exist as patients who are
selected, or who self select for screening trials are those who are likely to be more healthcare conscious, wealthier
and non-representative of the population as a whole.
In your answer you should know about a current NHE screening programme, for instance, that for breast cancer,
and be able to discuss one or two of the controversies associated with it.

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Medical Ethics

What are the four key principles of medical ethics? Where are they used and how can they come into conflict?

The four key principles are:

• Autonomy
• Non maleficence
• Beneficence
• Justice

‘Autonomy’ relates to the right of a person to make independent decisions concerning their own well being.
This has become of increasing importance as the NHS has shifted from a paternalistic model (doctor centred) to
a patient centred approach, where decisions are made collegiately, rather than on the say of a senior clinician.
Recognition of autonomy is reflected in the need for patient consent before any invasive procedure or
examination.

‘Non maleficence’ means that your intervention should not do harm to your patient [and comes from the latin
‘primim non nocere’, which means ‘first, do no harm’. This is reflected in risk-benefit analysis for every procedure.
If the potential for harm outweighs the chance of benefit, then a procedure is not thought to be in the patient’s
best interest.
Beneficence refers to actions that serve the best interest of a patient or more literally, actions that ‘do good’ for
the patient, whilst the principle of justice would suggest that all patients should be treated equally and without
prejudice. In modern practice, this means that doctors should not treat patients differently based on race, gender
or sexual orientation.

Conflict can arise where two of these pillars are in apparent opposition. A classic example of this could be in a
patient who is Jehovas witness and did not want to accept a blood transfusion where clinically indicated. In this
case your responsibility to recognise and respect their autonomy would conflict with the pillars of beneficence
and non malificence if you believed that withholding the transfusion would increase the chance of harm.

Some doctors would say that the practice of euthanasia respects a patients autonomy and right to make their
own choices about their own care, whilst others would say that assisting a patient’s death contravenes the most
basic of tenets of ethics, that of ‘primum non nocere’. Equally it could be argued that by not carrying out the
wishes of a patient without the capacity to end their own life, the pillar of Justice is not applied, because we are
discriminating against an individual without the ability to carry out their own wishes due to a physical
impairment.

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Medical Ethics

Advice

Ethical questions are relatively common and may involve a clinical scenario. Stations that have appeared in the
past include
Unconscious patient with a ruptured AAA, whose family tell you is a Jehovahs witness

A patient with learning difficulties needs an operation, can they consent?

Should a 14 year old girl be able to consent to an abortion without the knowledge of her parents?

Questions concerning ethics are rarely straightforward and do not commonly have a right or wrong answer. A
good answer will look at both sides of an argument and not be too narrow minded in its approach. Do not try to
be too structured in this sort of question. The panel expect you to think freely and show the humanity that is part
of the make up of a good surgeon. It is absolutely acceptable to have your own view and to hold it strongly, but
you must also show the ability to empathise with those with a differing opinion, even whilst maintaining your
standpoint.

A good answer will look at both sides of an argument and not be too narrow minded in its approach. Do not try
to be too structured in this sort of question. The panel expect you to think freely and show the humanity that is
part of the make up of a good surgeon. It is absolutely acceptable to have your own view and to hold it strongly,
but you must also show the ability to empathise with those with a differing opinion, even whilst maintaining your
standpoint.

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Statistics

What do you understand by a null hypothesis?

A null hypothesis is a default or general position. An example would be to say that there is no relationship
between two variables or that one outcome was not a result of a certain factor. It is typically set against an
‘alternative hypothesis’ (also known as a research hypothesis). The two are compared using one of any number of
statistical tests. The aim of the statistical test is not to prove the null hypothesis, as this is not possible, but instead
a set of data can reject a null hypothesis (if the default position is not shown to be statistically true) or to fail to
reject it (when the default position is held)

What is a confidence interval?

A confidence interval indicates the reliability of an estimate. It is based on a sample of quantitative data. It
defines the frequency of a parameter being contained within a certain interval. Example, if the mean in a
population sample was 60, and the upper and lower limits of the 95% confidence interval are 65 and 55
respectively, you can therefore conclude that there is a 95% probability that the true population mean is greater
than 55 and less than 65.

What do you understand by a gaussian distribution?

A Gaussian distribution is more commonly known as a normal distribution and is one of the most commonly
illustrated probability distributions in statistics. It always represents continuous, quantitative data. It is a
distribution where the pattern of distribution above and below the mean is identical. It forms a classical ‘bell
shaped probability density function’ and is commonly encountered in social and medical science.

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Management Station
Clinical governance

What is your experience of clinical governance?

I have been a part of clinical teams where all aspects of clinical governance are demonstrated, but have not as yet
been personally fully involved in all the pillars of clinical governance.

I developed a handbook for the management of non-complex orthopaedic injuries being seen in A&E. This was
based on NICE guidelines concerning these injuries and reflected the fact, that previously some patients had
been receiving inappropriate care in some cases. I performed an extensive literature review of these common
injuries and worked alongside a senior registrar to produce an intranet based protocol which is now used on a
daily basic in the A&E at the hospital. By doing this, I was able to improve the clinical effectiveness of the A&E
department, introducing evidence based practice to an area where things were previously suboptimal.

When the issue of the management of these injuries was first raised my my orthopaedic consultant, I was unsure
whether this was a valid problem. I conducted an audit of the treatment given at that time. I used current NICE
and RCOS guidelines as my standard and found that the department fell below the expected target in terms of
patient readmissions and post operative pain. 3 months after the introduction of the handbook, I re-audited that
same unit and found that there was a statistically significant improvement in treatment of the cases mentioned in
the pamphlet. I feel that my intervention led to a marked change in practice.

I have taken an active role in teaching and training senior medical students. I am currently completing a part-
time teaching diploma at the University of London and have published a peer reviewed article on effective
clinical communication for International students at Undergraduate level. I teach anatomy to 3rd and 4th year
medical school students once a week. I collect verbal and electronic feedback via a pro forma that I designed
online. The feedback so far has been very good, although my teaching methods are not perfect, this allows me to
subjectively assess the strengths and weaknesses of my style.

I recently completed the European Computer Driving Licence. This has given me relevant skills to be able to use
information technology to improve efficiency in the workplace. I have developed an online reporting system
whereby fellow foundation doctors are able to discuss concerning clinical issues and questions on an anonymous
basis. Anecdotally, this has reduced the incidence of errors made by junior staff, as we all feel more comfortable
discussing issues on which we are not clear. I plan to audit the results of this pilot in the near future. This forum
plays a role in risk management and reducing errors by junior staff.

I have become involved in rota design in the last year. This arose after a dispute between two colleagues and I feel
that it has improved my organisational skills hugely. The feedback on the changes that I have made has been
excellent, with a reduction in the number of ‘split shifts’ that FY1 and FY2s had to complete, often meaning that

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Management Station
Clinical governance

they previously finished at 2 or 3am. I believe that I have had a good exposure to a number of aspects of clinical
governance and hope to develop these interests in coming years.

Advice

Clinical governance is a process of quality assurance to ensure that standards of care are improved and that
public accountability is maintained. It is based around 7 pillars which are Clinical effectiveness and Research,
Audit, Risk management, Education & training, the use of IT, Medical staffing and Patient and public
involvement. It is tempting just to reel these off, especially if you happened to have learned them verbatim, but if
you read the question, you will see that it is asking what your experience has been. Your answer can be framed in
terms of these ‘pillars’ and you could even start with a very brief description of them, but you must detail which
experiences you have had that is relevant and how they make you a stronger candidate in the eyes of the panel.

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Management Station
Consent

You are the surgical Senior House Officer (SHO) on call. You are informed by the staff nurse that your
consultant has asked for you to consent the patient who is next on the operating list because both he and the
registrar are busy with the current case which is already one hour late. You have no knowledge of the
procedure that you have been asked to seek consent for. What do you do?

This is a difficult situation because I cannot take consent in order to maintain patient safety. According to the
GMC guidelines, ideally, the person doing the surgery should obtain consent from the patient. However, the
surgeon can delegate obtaining consent to someone else provided that person is suitably trained and qualified,
has sufficient knowledge of the proposed investigation or treatment and understands the risks involved, and
otherwise act in accordance with the guidance set out by the GMC and the Department of Health.
Unfortunately, in this scenario, I am not suitably qualified to seek consent.

I will inform the nurse why I cannot obtain consent and take the initiative to look for someone suitable, for
example another registrar or consultant who is competent in that procedure, to ask their help in consenting the
patient. Even if there is no one free to consent the patient and I feel pressured to do so myself, I still cannot
consent because of the GMC guidelines and patient safety implications. I will explain the situation to my
consultant when I meet him and apologise that I was not been able to find anyone to obtain the consent. I will
also convey my enthusiasm to observe him consenting the patient, assisting in the surgery and reading up on it so
that I obtain a good grasp of it and can consent patients for such a procedure in the future. In my experience,
most consultants would be understanding of this.

The consultant gets angry that you did not consent the patient and the theatre list is further delayed. He
shouts at you in front of the nurse, registrar and patient. What do you do?

In the first instance, I will not say anything because any discussion may result into conflict due to the emotions of
the situation. I will then arrange to meet the consultant in private later that day or the next day. Once I am with
the consultant, I will ask for an explanation for the shouting. I would discuss with the consultant if he has
identified areas of concern about my performance. If so, I would ask his advice on how I could resolve it.
Nevertheless, I would still politely point out that it was not professional to shout at me in public. I would hope
that this would resolve the situation for both of us.

The consultant has been verbally aggressive towards you on more than one occasion and does not admit that
his behaviour was unprofessional. How would you respond to this?

In this situation, it seems that any further discussion with the consultant would be unproductive and may even
lead to conflict. I would then escalate this to my educational supervisor for advice and support. If this consultant
was my educational supervisor, I would seek advice from other consultants. If they are not helpful, I would
escalate to the clinical director and even the medical director if needed.

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Management Station
Consent

What does consent normally involve?

Consent is a multistage process that has been described in GMC’s good medical practice in a basic model:

Condition
The doctor makes a clinical assessment of the patient’s condition based on the history, examination and
investigations and explains the diagnosis as appropriate.

Options
The doctor discusses options for the investigation or treatment of likely benefit using their specialist knowledge
and taking into account the patient’s views and understanding of their condition. The doctor takes care in
explaining the potential benefits and risks of each option (conservative, medical and surgical), including the
option of no treatment.

Informed decision making

The patient weighs up the potential benefits and risks of the various options before communicating their decision
to the doctor.

Since consenting is a process where the patient is empowered to make an informed decision, it can be time
consuming depending on the complexity of the condition and the treatment. Therefore, in the above scenario,
initial consent should have taken place when the patient was seen in clinic or pre-assessment. On the day of the
surgery, consent should then be confirmed before proceeding.

What types of consent forms are used in the NHS?

4 forms are commonly used.

Form 1 Patient agreement to investigation or treatment (adults with capacity)

Form 2 Parental agreement to investigation or treatment (i.e. for children)
Form 3 Patient/parental consent for procedures where consciousness of the patient is not impaired
(i.e. patient is alert throughout the procedure)
Form 4 Adult unable to consent for investigation or treatment (i.e. lack capacity)

Please note that signing a consent form without going through the actual consent process described above is
invalid and would be useless if such a case were taken to the court of law in the event of a post-operative
complication.

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Management Station
Taking the initiative

Your consultant, who is the general surgery clinical lead, wants to find out whether the surgical team is doing
venous thromboembolism (VTE) assessment promptly within 24 hours of admission of a patient and VTE
prophylaxis prescribed as appropriate. He delegates this task to you. How would you investigate this?

I would investigate this by undertaking an audit in the department. I would register the audit with the Trust audit
department after discussion with my consultant. I would first pilot the audit by going through the medical
admission notes and drug charts of the last 5 patients admitted to the ward. Once I am happy with the data set
that needs to be collected for analysis, I will embark on this retrospective audit looking at the notes and drug
charts of all the patients admitted on the ward. I will collate the data and look for ways of improving compliance
with VTE assessment, if low. I will present it at the next Clinical Governance meeting and suggest my
recommendations for improving practice. Following discussion of the audit and agreement of new
recommendations, I would like to repeat the audit cycle once the changes are implemented. I would do a
prospective audit looking at the same data sets so that I can compare and present the findings to check whether
the recommendations have actually led to improvement of practice.

This question can be answered in many different ways. How ever you decide to answer, its important to the show
initiative any consultant would like to see in the people they are training.

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Management Station
Revalidation

What do you understand by revalidation?

Revalidation is a process by which licensed doctors are required to demonstrate to the GMC that they are up to
date and fit to practice on a regular basis. It is a means to promote and ensure continuing medical education,
standards of practice and fitness to practice. It also helps identify doctors in difficulty who require additional
support.

Since its launch in December 2012, revalidation is a legal requirement for all doctors. This revalidation process
occurs every five years, by having regular appraisals with the employer that are based on the four domains of
GMC’s Good Medical Practice (knowledge, skills and performance; safety and quality; communication,
partnership and teamwork; maintaining trust).

For trainees (StR/SpR), the responsible officer who makes the revalidation recommendation is the postgraduate
dean of the Local Education and Training Board (LETB, previously known as the deanery). This
recommendation is based on the appraisal done at the Annual Review of Competence Progression (ARCP) after
assessing the supporting evidence provided by trainees corresponding to the four domains of GMC’s Good
Medical Practice.

How would you, as a surgical trainee, provide evidence for the revalidation process?

During my surgical training, I would use the Intercollegiate Surgical Curriculum Portfolio (ISCP) to record
evidence of my ongoing training and professional development as well as feedback from 360 degree appraisals.
My responsible officer would then assess this evidence at my ARCP before making a recommendation to the
GMC.

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Management Station
Cancelled Theatre List

You are working with the Vascular Team today and you have been called by a nurse to say that the Triple A that
was planned for today has been cancelled as there are no ICU beds. This patient has been cancelled twice
previously for other reasons.

How do you proceed?

Firstly I would confirm with the theatre co-ordinator and inform my Consultant and the rest of the team
(Theatre an ward nurses, SpR, Anaesthetist etc) this was the case.
Then I would call the ICU SpR to see if there was any possible chance that another surgical patient was well
enough to be stepped down from ICU and transferred to HDU or the ward with increased clinical supervision,
thus freeing up a bed.

This is not the case and ICU tells you there are absolutely no beds free

I would go straight to the patient and explain the situation, apologizing that this has happened. If possible I
would ask my Consultant to come with me when I do this. I would re-book the patient on the next possible
theatre list and book an ICU bed at the same time, confirming it myself with the ICU staff. This would all be
done before the patient left the hospital, so they had a future date planned.

You find out that the original ICU bed had not been booked properly anyway and was a last minute request.
How could you prevent this happening again?

A patient has been cancelled on a list for the third time now, this therefore requires a DATIX (incident) form to
be written, particularly in this case. I would confirm exactly how and ICU bed should be booked and during the
next team meeting relay this information to the rest of the team. If this has happened on many occasions it may
be worth auditing this and reviewing the procedure for booking a bed.

Is there anything else you could do now that the patient has been confirmed as cancelled?

With this cancellation there leaves a lot of free time on the theatre list. I would se if there were any inpatients/
emergencies that we could bump onto our list instead, discussing with my Consultant and theatre Coordinator.

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Acknowledgements
With many thanks to all of our excellent contributors, we thank you for your time and effort.

For any future contributions, or to get involved in the core surgical interview course, please contact us at
[email protected]

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Conclusion
This guide aims to de-mystify the core surgical interview by giving you some hints and tips that
we would like to have had before we applied. It has been written by surgeons in the first few
years of their career. Unlike other guides out there, it is based on recent experience of the
interview. It is an essential companion to the surgical interview course, and you will be expected
to have read most of it before attending.

We recommend you start practicing these stations as soon as possible with your colleagues who
are also applying. The more practice you get the more confident you will feel and the better you
will be come interview.

We hope that you have had as much fun reading this guide as we have had writing it!

Don’t forget to visit www.surgicalinterview.co.uk and join us for our course. There are several
locations around the country, but it is again expected to book up quickly. Please secure your
place early to avoid disappointment

Good luck!

The (ever growing) Core Surgical Interview Team

KC Surgical Training LTD

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