Communication Skills:

Colonoscopy risks:
Bleeding from the site of the tissue sampling. Usually
this stops on its own and if it doesnt it can be treated
with cauterisation or injection treatment. The risk is 1
in 200.
- The sedation can sometimes cause breathing or blood
pressure problems so this is monitored closely following
the procedure.
- A more serious risk is perforation or a tear in the
bowel lining which nearly always needs an operation to
repair. The risk is 1 in 1000.
So that we can have a good clear view of the bowel, you will
need to be on a low fibre diet and drink plenty of fluids 2 days
prior to the procedure. The day before, you should have clear
fluids only including black tea/coffee with sugar, glucose
drinks, clear soups.
You will also need to take a laxative which will explain when to
take it on the label.
Because of the risk of increased bleeding, you will have to stop
your aspirin 7 days before the procedure. You can restart it
immediately after the procedure.
The results of the tissue biopsy take 2 weeks. You will be seen
in the outpatient clinic following the procedure to discuss the
findings of the investigation.
Consent tips:
-Introduce yourself and gain understanding of what the patient
understands so far.
-Explain the procedure and tissue sampling. It is helpful to
draw a diagram if you can do this quickly.
-Explain that sedation and analgesia are administered.
-Explain alternatives and limitations barium enema.
-Risks Bleeding, infection, risks of sedation, perforation.

-Explain bowel preparation methods.

-Inform them when to be NBM and to take their regular
medications.
-Summarise if necessary
understand
-Offer information leaflet.

and
the

keep

checking

that they
information

Bad news in general:

Appropriate environment. Most commonly a relatives room or
an office where you know you will not be disturbed is the most
appropriate place.
Ensure that there are no distractions: You should leave your
bleep with a colleague so that you are not disturbed at a
sensitive time
You should always have another member of the MDT present
with you, most commonly another doctor or nurse who knows
the patient
Ensure that you know the patients history
Ascertain how much the relative or patient knows
Show empathy
Give a warning sign or shot before you deliver the bad news
and follow this by an appropriate pause. Do not be scared of
silence
Try and pitch your language at the correct level, do not get
too technical
Start with an open-ended question
Can I ask how much you know about your husbands current
condition?
You are breaking bad news so you should fire a warning shot
first.
I am afraid it is not good news.
After telling a patient or relative any form of bad news it is
essential to pause and allow a period of silence. This will give

them time to process what you have just said. Do not continue
with the conversation until the patient or relative is ready.

It is impossible to tell how someone will react to this

information. Try practicing with a fellow candidate a variety of
reactions from sadness to anger and see how you get on: the
actors in the exam can act all of them!
I understand your concerns and under no circumstance would
we starve or ignore Mr Smith. There has been a lot of publicity
about the Liverpool Care Pathway recently and not all good.
Can I explain exactly what the pathway is?
The Liverpool Care Pathway or LCP as some people call it is a
pathway used to give dignity in the dying. We would not
withhold food or fluids unless from your husband. At all times
we will make your husband as comfortable as possible by
providing pain relief, anti-sickness medications and we will not
be using deep sedation. We will provide regular mouth care
and change his position in bed to make him as comfortable as
possible as long as it is not too distressing. We will not be
carrying out any routine tests as they can also be distressing
and do not give us any added information, but we will regularly
review Mr Smiths condition. I would like to stress that we will
provide the best care possible for your husband and you can
spend as much time on the ward with your husband as you
wish.
Close the conversation by saying that you can be contacted by
the nurses if there are any other questions or concerns that
arise.
Then ask Mrs Smith if she would like to go and see her
husband.
Although this conversation may seem short, if you are delivery
your statements at the right pace and allowing appropriate
silences then it should take 8 - 10 minutes.
When breaking bad news you should have the following points
in your mind:

 Appropriate environment. Most commonly a relatives room or

an office where you know you will not be disturbed is the most
appropriate place.
Ensure that there are no distractions: you should leave your
bleep with a colleague so that you are not disturbed at a
sensitive time
You should always have another member of the MDT present
with you, most commonly another doctor or nurse who knows
the patient
Ensure that you know the patients history
Ascertain how much the relative or patient knows
Show empathy
Give a warning sign or shot before you deliver bad news and
follow this by an appropriate pause. Do not be scared of
silence
Pitch your information-giving at the correct level
Provide information as to how the patient or relative can
contact you if they have further questions
The Liverpool Care Pathway was developed in the late 1990s
for the care of terminally ill cancer patients. Since then the
scope of the LCP has been extended to include all patients
deemed
dying.
The LCP has been recognised nationally and internationally
as a good model to support the dignity of a dying patient. It is
supported
by
the
GMC
and
NICE.
The LCP is built around maintaining the highest possible
dignity
of
the
dying
patient
The LCP should be used when there is no further treatment
that a patient can have and it is recognised that they are in the
last
days
or
hours
of
their
life
The LCP does not hasten death. It is not euthanasia
The LCP does not stop a patient from having oral intake or
artificial
hydration
The LCP does not use deep, prolonged sedation
The LCP does not interfere with a patients religious beliefs
The LCP should be regularly reviewed (every 4 hours)

 Through the pathway good communication is essential with

the patient, relatives and amongst the MDT
Saying sorry is a crucial step in dealing with an angry patient
(even if it is not your fault!). It does not admit liability, but
expresses empathy for the other persons situation. It quickly
diffuses the situation and allows you to get to the bottom of
the problem.
If you can, it is useful to offer the patient some reassurance
that you will look into the problems (in this case that he had
not been contacted) and try to ensure it doesnt happen again.
Ensuring that you have the correct contact details reassures
the patient that you intend to contact him, and also eliminates
a common source of error in taking down wrong numbers.

Actually identify that you re the on call doctor

Clarify patients perspective
Do not falsely reassure patient
OGD consent:

Yes thats right. The camera test is called an oesophagogastro-duodenoscopy,

which
is
shortened
to
OGD.
It is a camera, known as an endoscope, which is inserted
through the mouth, down the food pipe, into the stomach and
along to the first part of the small bowel. {You can draw a
quick
diagram
to
demonstrate
this}
The camera then relays the image onto a TV screen so we can
have a look inside and see what may be causing your
symptoms. We may also need to take some tissue samples
from the lining of your digestive tract to help us with our
diagnosis. Typically, this doesnt hurt.
Does that make sense so far?

Yes I can appreciate that. There are two options. You can either
have local anaesthetic sprayed into your throat to numb the
area or you can be sedated (that is, not asleep but you won't
remember). The benefit of having local anaesthetic spray
means that you can go home straight after the procedure and
you can drive. You would just need to avoid hot drinks until the
numbness has worn off in around 30-60 minutes. If you have
sedation, you will need someone to accompany you home and
stay with you until the next day. You cannot drive for 24 hours.
You will likely be able to go home the same day if you are well
and have managed something to eat and drink.
Unfortunately, no procedure is without risk. The possible
risks involved with this procedure are:
Bleeding
from
the
site
of
tissue
sampling.
- Infection, such as a chest infection if some fluid passes into
the
lungs.
- There is also a risk of damage to the teeth from the
endoscope.
- A slightly more serious risk is a perforation or tear of
the lining of the digestive tract which may need an
operation to repair. The risk of this is 1 in 1000.
It is normal to expect a sore throat for a few days afterwards.

If your appointment is in the morning, take no food or

drinks after midnight.
If your appointment is in the afternoon, you may have a light
breakfast no later than 8am, but no food or drinks after that.
Small amounts of water are ok to take up to two hours before
the procedure.
Yes, take your regular medications in the morning.
TIPS for ogd consent:

-Introduce yourself and gain understanding of what the patient

understands so far.
-Explain the OGD procedure and tissue sampling. It is helpful to
draw a diagram if you can do this quickly.
-Explain that it can be done under local anaesthesia or
sedation.
-Explain alternatives barium swallow/meal Xray.
-Expect a sore throat afterwards.
-Risks Bleeding, infection, damage to teeth, perforation.
-Inform them when to be NBM and to take their regular
medications.
-Summarise if necessary and
understand the information.

keep

checking

that

they

-Offer information leaflet.

CT referral tips :

These scenarios typically start with a preparation station to

familiarise yourself with the patients history and examination
findings based upon a set of case notes.
Ordering imaging out of hours can be a challenge as there
are fewer resources available.
It is important to be clear about what you want in terms of
imaging and urgency, with a clear rationale.
You may be challenged more than you would be during
normal working hours, particularly as a junior doctor, but it is
important to stay calm and focus on the clinical issues.
It is important not to make things up this will reflect very
badly in the exam scenario.

Introduce self and clarifie on the phone, clear initial request

rationale, emphasize urgency of re
quest, suggest sensible
important findings on CT, be calm and effective when
challenged,
OFFER SENSIBLE PLAN OF ACTION BASED UPON PROSPECTIVE
CT FINDINGS
Honest about not having renal function to hand
Express empathy for demand upon the radiology deparment

Contrast conta: (renal impairment risk factos, allergy)

Operative

Whenever you perform any surgical procedure in the

OSCE start by checking the consent form, including patient
name, DOB, hospital number, site and side of lesion. Not doing
so could be considered battery. Complete the WHO checklist
Position the patient so that you are both comfortable, and so
that you have easy access to the lesion
Prep and drape the area using the iodine or chlorhexidine
solution, and the drapes available. If no prep / drape is
available, state you would fully prep and drape the patient
Check the local anaesthetic with the examiner state aloud eg
1% xylocaine with 1:200000 adrenaline, expires July 2017
Inject the local anaesthetic, give it a moment to work, and then
test sensation gently with a sharp instrument.
Make an elliptical incision around the lesion, keeping the
scalpel blade perpendicular to the skin at all times.
Use toothed forceps to elevate the edge of skin so that you can
undermine it, and excise the lesion in its entirety by cutting

through the fatty layer with either the knife or dissecting

scissors.
Once removed, place in a sterile specimen pot and state you
would label and send to pathology.
Now pick up the nylon suture with your needle holders and
close the wound using your preferred technique, for instance a
vertical mattress suture. If the wound created is large it may
be necessary, especially with the unrealistic toughness of the
prosthetic skin, to undermine the skin edges, and use a vicryl
suture to bring the edges closer together.
It doesnt matter which suturing technique you use as long as
it is a recognizable one, and the correct suture material is
selected
Once the edges are nicely opposed place a mepore dressing
and offer to bandage the arm
Thank the patient
Wash your hands
Actinic keratosis is a premalignant skin lesion that is induced
by UV light. It can progress to squamous cell carcinoma
On histology SCC is characterized by proliferation of atypical
keratinocytes, invasion of the dermis and keratin pearls
The dressing should remain on and dry for a week
When should the patient have their sutures removed?
Between 5 and 10 days

I would use lidocaine 1% at a dose of 3mg/kg.

1% means 10mg lidocaine/ml.
Bupivacaine has a longer period of activity and slower onset,
so is not as preferable to lidocaine in this situation.

Adrenaline:
1. Prolongs duration of activity.
2. Slows systemic absorption of LA.
Hence, higher doses may be used (e.g. lidocaine 7mg/kg as opposed
to 3mg/kg).

Patients may have an anaphylactic reaction to the LA, or they

may complain of perioral tingling and parasthesia progressing
to drowsiness, seizures, coma, apnoea, paralysis, arrhythmias
and shock (LAs are negative inotropes and vasodilators).
Management would be:
1. Stop administering LA
2. ABCDE management (give more details if asked - primarily
airway protection)
3. Inform ITU - may require ventilation
4. IV fluids
5. Cardiovascular support (e.g. inotropes)

The histology will normally be available after it has been

discussed in an MDT; this takes a week or two. The patient will
be contacted by post or a phone call to inform them of the
diagnosis and any follow up that is required
Whenever you perform any surgical procedure in the OSCE
start by checking the consent form, including patient name,
DOB, hospital number, site and side of lesion. Not doing so
could be considered battery. Complete the WHO checklist
Position the patient so that you are both comfortable, and so
that you have easy access to the lesion
Prep and drape the area using the iodine or chlorhexidine
solution, and the drapes available. If no prep / drape is
available, state you would fully prep and drape the patient
Check the local anaesthetic with the examiner state aloud eg
1% xylocaine with 1:200000 adrenaline, expires July 2017
Inject the local anaesthetic, give it a moment to work, and then
test sensation gently with a sharp instrument.
Make an elliptical incision around the lesion, keeping the
scalpel blade perpendicular to the skin at all times.

Use toothed forceps to elevate the edge of skin so that you can
undermine it, and excise the lesion in its entirety by cutting
through the fatty layer with either the knife or dissecting
scissors.
Once removed, place in a sterile specimen pot and state you
would label and send to pathology.
Now pick up the nylon suture with your needle holders and
close the wound using your preferred technique, for instance a
vertical mattress suture. If the wound created is large it may
be necessary, especially with the unrealistic toughness of the
prosthetic skin, to undermine the skin edges, and use a vicryl
suture to bring the edges closer together.
It doesnt matter which suturing technique you use as long as
it is a recognizable one, and the correct suture material is
selected
Once the edges are nicely opposed place a mepore dressing
and offer to bandage the arm
Thank the patient
Wash your hands

The main complication of diathermy is a burn to the patient.

This can happen through operator error through contact with
the skin, or through incorrect placement of the patient
electrode. These can be minimised by careful technique, and
by placing the patient electrode correctly on dry, shaven skin,
away from bony prominences, with a good contact established.
Other risks with diathermy include interference with
pacemaker function, ignition of volatile gases and liquids which
might occasionally be used in theatre, and arcing of a spark via
other metal surgical instruments so that a burn occurs at a site
distant to the electrode.
The patient has had a right-sided hip replacement. Where
would you place the patient plate electrode?
In this case it should be placed on the patients left mid thigh,
sufficiently far away from the operative site, the pacemaker,
and the prosthetic hip.
In monopolar diathermy current passes from the active
electrode through the tissues being operated on to an
electrode plate on the patient. The current is disseminated
thought a larger surface area of at least 70 cm2 than it
originated in, therefore preventing a heating effect at the plate
electrode.
In bipolar diathermy, current passes between the two tips of
the active electrodes, therefore only passing though tissue that
lies between the tips. There is no plate electrode.
Post abdominal aortic aneurysm surgery and in light of their
COPD the patient should have a bed booked on HDU or ITU, as
it is likely that he will need close monitoring and is at high risk
for respiratory problems post operatively.
Patients with COPD have a several fold increase (2.7-4.7x) in
postoperative complications including atelectasis, pneumonia,
and respiratory failure.
The risk of pulmonary complications can be reduced through
smoking cessation at least 4-8 weeks before surgery
and early mobilization following surgery.

Pre- and postoperative respiratory physiotherapy to provide

deep
breathing
exercises,
intermittent
positive
pressure breathing, and incentive spirometry can help
reduce complications.
Postoperatively, adequate pain relief and an upright position in
bed should aim to ensure the patient is able to cough and that
the diaphragm is not splinted.
Before deciding I would like to have more information on the
patients current condition, and severity of their comorbidities.
It would probably be more appropriate for the elective
abdominal aortic aneurysm to be first on the list as it is the
largest, most complex and appears to be the most urgent case.
I would place the inguinal hernia operation second and the
varicose vein stripping last, especially because of the MRSA. I
would confirm this with my consultant before submitting the
revised list.
The main priority for list order is the clinical urgency of case. If
an operation is needed to save a patients life it takes priority
regardless of other issues.
Traditionally dirty cases and patients with MRSA are put last
on the list to facilitate adequate cleaning of the operating
theatre.
This is not always necessary provided the cleaning of relevant
surfaces can be done adequately before the next patient. After
the patient has left any surface the have come into contact
with should be cleaned with an approved detergent and hot
water. It should then be left to dry for at least 15 minutes
Diabetic patients should be placed early on the theatre list, to
reduce the chance of hypoglycaemia.
Operative list order can vary from surgeon to surgeon, and in
this station, it is not the actual order you place the patients in
that scores marks, rather the fact you have shown
understanding of how co-morbidities may impact on surgery.
You have limited information about the severity of the patients
condition, which you should acknowledge. One method to
answering this question is to list the patients in order from
most major surgery to most minor, and then take into account

the comorbidities, placing dirty cases and those with MRSA last
unless they happen to have a good reason to go first e.g.
they are diabetic, or the surgery is more clinically urgent, those
with diabetes first, and those with major comorbidities early.
This can be quite a quick-fire station, so make sure you give a
clear answer before offering an explanation for your reasoning
- if the examiner is happy with your answer they may want to
just move on to the next question.
Prepping and draiping
1. Hair over the incision site should be removed.
2. Skin prep should be applied in concentric circles moving
toward to the periphery.
3. The prep area should include space to be able to include all
incisions, extend any incisions or insert drains.
4. Dab any pooling of skin prep (eg in umbilicus) to prevent
burns when using diathermy.
5. Only dry the edges where the skin drapes are to be applied.
An antiseptic is an agent applied to living tissue
A disinfectant is an agent applied to an inanimate surface
Chlorhexidine Gluconate
-Broadest spectrum, potent activity against Gram ve and +ve
bacteria
-Some activity against viruses
-Better residual activity - effective for >4 hrs
-Poor against spores and fungi
Betadine
-Potent against bacteria, fungi and viruses incl TB
-Some activity against spores
-Can cause skin irritation
-Effective for <4hrs
Isopropyl Alcohol
-Broad spectrum against bacteria, viruses, fungi, TB
-No activity against spores
-Fast-acting

What are the principles of draping?

-Separates dirty from clean
-Provides a barrier to prevent microorganism spread
-Covers equipment to protect the equipment and the patient
from unsterile equipment
-Controls fluids to keep patient dry and minimise exposure to
healthcare worker when cleaning up
-An incise drape can be used to create a sterile field when
performing skin incision
What characteristics do you look for in a drape?

-1 Resistant strong enough to withstand wet or dry stresses

-2 Barrier resist penetration of microorganisms or fluids
-3 Non-toxic material
-4 Flexibility able to drape around objects
-5 Electrostatic properties accept or dissipate electrical
currents
-6 Breathable
-7 Non-inflammable

Patients need to be prepped prior to draping. This involves

removing any hair over the incision site and using skin prep.
An antiseptic is an agent applied to living tissue
A disinfectant is an agent applied to an inanimate surface
Chlorhexidine Gluconate
-Broadest spectrum, potent activity against Gram ve and +ve
bacteria
-Some activity against viruses
-Better residual activity - effective for >4 hrs
-Poor against spores and fungi
Betadine
-Potent against bacteria, fungi and viruses incl TB
-Some activity against spores

-Can cause skin irritation

-Effective for <4hrs
Isopropyl Alcohol
-Broad spectrum against bacteria, viruses, fungi, TB
-No activity against spores
-Fast-acting
The principles of drapes are to create a sterile field, provide a
barrier, cover equipment and provide a sterile field when
performing a skin incision.
Drapes need to be resistant to wet and dry, a barrier, nontoxic, flexible, have electrostatic properties, breathable and
non-inflammable.
The NECPOD classification of intervention is the most widely
used
It has arise from the National Confidential Enquiry into Patient
Outcome and Death
It came into effect in 2004
I - Immediate. Life saving. Resuscitation and intervention
simultaneously. Examples: Ruptured AAA. Major thoracic and
abdominal trauma
Ia - Within 6 hours. Organ or limb saving. Resuscitation
required prior to theatre. Examples: Bowel perforations. Closed
loop obstruction
II - Within 24 hours. Appendicitis
III - Expedited. Stable patient where decision to operate within
days. Example: colonic tumour that is going to obstruct
IV - Elective
The NECPOD classification of intervention is the most widely
used
It has arise from the National Confidential Enquiry into Patient
Outcome and Death
It came into effect in 2004
I - Immediate. Life saving. Resuscitation and intervention
simultaneously. Examples: Ruptured AAA. Major thoracic and
abdominal trauma
Ia - Within 6 hours. Organ or limb saving. Resuscitation
required prior to theatre. Examples: Bowel perforations. Closed
loop obstruction
II - Within 24 hours. Appendicitis
III - Expedited. Stable patient where decision to operate within
days. Example: colonic tumour that is going to obstruct
IV - Elective

American Society of Anaesthesiologists scoring for patients

undergoing surgery to classify risk.
Predicts morbidity and mortality
1 Fit & well patient Mortality 0.05%
2 Mild systemic Mortality 0.4%
3 Significant systemic disease but well controlled Mortality
4.5%
4 Severe systemic disease that s a constant threat to life
Mortality 25%
5 Moribund and not expected to survive more than 24 hours
with or without surgery Mortality 50%
ASA
ASA
ASA
ASA

2
3
4
5

=
=
=
=

well controlled asthma or hypertension

Stable angina
Unstable angina or advanced COPD
multi-organ failure

What is the definition of a laparotomy?

Any incision that accesses the peritoneal cavity
What layers are cut through when performing midline
laparotomy?
Skin
Subcutaneous fat
Scarpas fascia
Linea alba
Transversalis fascia
Extra-peritoneal fat
Peritoneum
It must provide good access to the abdomen
It should have the capacity to be extended
Muscles fibers should be split rather than cut
Nerve damage should be minimal
Ease of closure
Can you name the following abdominal incisions and give
examples of what operation they may be used for?

Blue = roof top. Access to oesophagus, stomach, liver

Red = Kocher. Biliary tree. Open cholecystectomy
Yellow = Midline. Virtually all abdominal operations can be
performed via this approach
Green = Paramedian. Access to the spleen
Purple= Lanz. Open appendectomy
Orange = Pfannenstiel. Pelvic surgery

Supine position: The most common surgical position. The

patient lies with their back flat on operating table
Trendelenburg position: supine with head down
Reverse Trendelenburg position: supine with head raised

Lithotomy position: Thorax and trunk are supine whilst

the legs are flexed at the hips and knees. The ankles
are placed in stirrups
Lloyd Davies: Similar to lithotomy but the ankles and
calves are supported in pneumatic stirrups
Prone: Patient lies with stomach on the operating table
Lateral position: patient is placed on their side
How can you classify wounds?
Mechanism, contamination and depth
Mechanism:
Incised wounds: Epithelium is breached by a sharp object.
Example: surgical incision or facial wound caused by a glass
bottle
Laceration: caused by stretching, tearing or blunt trauma.
There is failure of the dermis. Examples: scalp laceration
following blow to the head, pre tibial laceration in an elderly
lady who has fallen
Abrasion: friction against surface causing sloughing of
superficial layers
De-gloving: shearing of parallel tissue planes which separate
and causes tissue disruption.
Burns

Contamination:
Clean: Skin is breached in a planned manner but there is no
breach of the mucosa of respiratory, genito-urinary or gastrointestinal tracts. Examples: removal of skin lesion or
uncomplicated hernia repair
Clean contaminated: Mucosa is breached in a planned manner
with no obvious contamination. Examples: cholecystectomy,
uncomplicated appendicetomy
Contaminated: Macroscopic soiling. Examples:
cholecystectomy with spillage of infected bile, colonic
resection.
Dirty: laparotomy for peritonitis, wound debridement,
perforated appendix

Depth:
Superficial: involve only the epidermis and dermis. Heal
without scar formation. Example: superficial graze
Deep: involve layers deep to the dermis. Heals by granulation
tissue and scar formation

What factors can lead to post-operative wound infection and

dehiscence?
Local:
Excessive wound tension and wound not sutured correctly
(layers not apposed correctly)
Poorly planned incision
Poor blood supply. For example, excision of a basal cell
carcinoma on the face. A local flap may be used to reconstruct
the defect. If the base of the flap is too narrow the blood
supply to the flap may be compromised.
De-sterilisation during the procedure
General:
Elderly: thin skin
Smoking
Obesity
Malnourished
Immunosuppression: Diabetes mellitus, steroids,
chemotherapy
Renal failure
Liver failure
Post operative hypoxia
Natural
Silk
Catgut
Synthetic
Prolene
Ethilon
Vicryl
Vicryl Rapide
PDS
Absorbable
Vicryl

Vicryl Rapide
PDS
Cat gut
Non-absorbable
Silk
Prolene
Ethilon
Monofilament
Prolene
Ethilon
PDS
Multifilament
Vicryl
Vicryl Rapide
Silk
Cat gut
Source: Ethicon
Cat gut: 70 -90 days
Vicryl rapide: 42 days
Vicryl: 56 - 70 days
Monocryl: 91 -119 days
PDS: 180 - 210 days

Facial laceration, skin closure: prolene or ethilon

Facial laceration, deep tissue closure: vicryl rapide
Mass closure of a midline laparotomy: PDS
Bowel anastamoses: vicryl or staples
Vascular anastamoses: prolene
Securing a drain: silk
Neck incision form a total thyroidectomy: metal clips
Formation of a stoma: vicryl
What are the 2 most commonly used skin preparations?
Iodine based, Betadine
Chlorhexidine
What is diathermy?

Use of high frequency electrical current to produce heat

up to 1000 degrees celsius.
This is used to cut or coagulate
What is bipolar diathermy?
Diathermy where the current passes between 2 electrodes
(usually ends of forceps)
The current is only passing through the tissue between the
forceps
Diathermy plate is not required
Only coagulation is possible with bipolar
What is monopolar diathermy?
Diathermy where the current passes from instrument to a
distant electrode (plate), which is paced on the patient (usually
the leg)
Localized heating at the instrument but minimal heating at the
plate
The plate should not be placed over bony prominences or
scars. This may lead to burns.
What minimum area should the plate used in monopolar
cover?
Minimum of 70 square cms
With monopolar it is possible to cut, coagulate, spray
and blend.
What do you understand by the terms cutting,
coagulation, blend and spray?
Cutting:
Continuous current and sinus wave form
There is greater heat application than coagulation
Cutting causes cell water to vaporize and the cell
explodes

The temperatures reached are up to 1000 degrees Celsius

There is little coagulation with this setting
Coagulation:
Pulsing current and square wave form
The heat produced is less than cutting
This lead to cell death by protein denaturation and cell
dehydration
There is less tissue disruption that cutting
Blend:
Cutting and coagulation combination
Spray:
Coagulation over a wide area
What are the risks associated with diathermy?
1. Arcing if other metal instruments are touched. This can
occur in laparoscopic surgery when instruments are not in view
2. Channeling of the current. If a narrow pedicle is touched
3. Burn at plate site if not placed correctly
4. Burn if spirit based skin preps are used
5. nterfere with cardiac pacemakers and ICDs. Diathermy
should be avoided and if necessary only bipolar should be used
6.Diathermy smoke can be carcinogenic
Unfortunately you receive a needles tick injury. What should
you do?
Inform your colleagues around you
Stop what you are doing and de scrub
Make the injury site bleed by squeezing it firmly
Run the affected area under water and scrub with iodine
Inform Occupational Heath if in hours or report to the
Emergency Department if out of hours
A blood sample should be taken from yourself

A risk assessment must be carried out by the health

professional in Occupational Health or the Emergency
department
If deemed necessary Post Exposure Prophylaxis (PEP) must be
commenced
With consent a blood sample must be taken from the patient to
test for HIV, Hep C & Hep B
The NECPOD classification of intervention is the most widely
used for classify surgical emergencies
American Society of Anaesthesiologists grading predicts
morbidity and mortality
Risks associated with diathermy:
Arcing if other metal instruments are touched. This can occur
in laparoscopic surgery when instruments are not in view
Channeling of the current. If a narrow pedicle is touched
Burn at plate site if not placed correctly
Burn if spirit based skin preps are used
Interfere with cardiac pacemakers and ICDs. Diathermy should
be avoided and if necessary only bipolar should be used
Diathermy smoke can be carcinogenic
Cleaning is the physical removal of debris from a surface,
disinfection reduces the number of transmissible
microorganisms and sterilization kills microorganisms including
bacteria, fungi, spores and viruses.
Normally surgical instrument trays are sterilised using moist
heat in a steam autoclave.

It depends on her current risk. If she has recently been started

on warfarin for AF and the AF is the source of an emboli that
has led to vascular problems in the leg to be operated on, then
I would place her in the high risk thromboembolic category. I
would take advice from a consultant haematologist. They
might advise that she stop warfarin 4 days before surgery, and
commence subcutaneous low molecular weight heparin. This

would be withheld the evening before surgery, and then

restarted from 6h after surgery once haemostasis had been
achieved. I would ensure the INR had fallen to below 1.4 before
operating.

I note that Valerie Radcliff has had an anaphylactic reaction to

penicillin before. As there is a 10% cross over of allergy
between penicillins and cefalosporins, giving cefuroxime would
not be advisable.
Clostridium difficile is a Gram positive anaerobic bacillus, which
is often a commensal organism of the colon in hospitalized
patients. It is a leading cause of antibiotic associated
diarrhoea, the pathophysiology of which is thought to involve a
disturbance of the normal gut flora secondary to antibiotic use,
allowing Clostridium difficile to proliferate. It produces a toxin,
which can result in a pseudomembranous colitis which
presents as yellow, smelly diarrhoea.
No treatment is needed for asymptomatic carriers. Patients
with diarrhoea should be source isolated in a side room, have
any antibiotics they are on stopped if possible, and be
resuscitated with fluids as required. Definitive treatment is with
oral metronidazole or vancomycin for 10-14 days. They should
be assessed clinically on a daily basis, and have X-ray imaging

of their abdomen if the complication of toxic megacolon is

suspected. Severe colitis or toxic megacolon may require
surgical intervention via a laparotomy and resection of affected
bowel.
Before the operation, during consent, a brief history and
examination should be carried out and the notes and relevant
imaging reviewed to ensure the correct side has been listed on
the operating list. The patient should be marked on the correct
side by the responsible surgeon, and the side should be stated
clearly on the consent form that the patient is to sign. In
theatre, the patients identity, site and procedure to be
undertaken is confirmed with the patient, the surgeon, and
with relevant imaging before induction and before the skin
incision. The WHO surgical checklist should facilitate this
process.
I would like to know more about the patients, but in principle
the list order is fine. The diabetic patient should go first to
avoid hypoglycaemia. The next case is a major case, especially
as they have been on warfarin, and should be before the
arthroscopy. I would confirm the list with my consultant before
submitting it.
Principles of ordering a theatre list:
The main priority for list order is the clinical urgency of
case. If an operation is needed to save a patients life it
takes priority regardless of other issues.
Diabetic patients should be placed early on the theatre
list, to reduce the chance of hypoglycaemia.
Traditionally dirty cases and patients with MRSA are
put last on the list to facilitate adequate cleaning of the
operating theatre.

I would place Mrs Jarvis first on the list as she is diabetic and is
having major emergency surgery in the form of a laparotomy
for an abscess. Mr Smalls with COPD should go next, as a
patient with COPD is likely to require a greater recovery time,
and possibly stay in HDU overnight. I would put Mr Yip third
and Mr Malton last, as he has MRSA and is undergoing a minor

procedure. I would confirm this list order with my

consultant first before submitting.
Operative list order can vary from surgeon to surgeon, and in
this station, it is not the actual order you place the patients in
that scores marks, but rather the fact you have shown
understanding of how the co-morbidities may impact on
surgery.
You have limited information about the severity of the patients
condition, which you should acknowledge. One method to
answering this type of question is to list the patients in order
from most major surgery to most minor, and then take into
account the comorbidities, placing dirty cases and those with
MRSA last unless they happen to have a good reason to go
first e.g. they are diabetic, or the surgery is more clinically
urgent, those with diabetes first, and those with major
comorbidities early.

Preoperatively the GP or specialist diabetic team should

optimise glycaemic control, as this facilitates better recovery
from surgery. Perioperative management depends on the grade
of the procedure, the time the patient is scheduled the next
day and the type of medication they are on.
For insulin dependant diabetic patients such as Mrs Jarvis, it is
recommended that they should reduce their nighttime dose of
insulin to prevent hypoglycaemia whilst nil by mouth. If first on
the list, they should be fasted from midnight the night before,
and placed on an insulin-5% glucose sliding scale regimen with
hourly capillary glucose measurement to allow optimum
glycaemic control. This should continue until they are eating
and drinking after the operation, at which time their normal
insulin regimen can be restarted.
Patients with COPD have a several fold increase (2.7-4.7x) in
postoperative complications including atelectasis, pneumonia,
and respiratory failure.
The risk of pulmonary complications can be reduced though
smoking cessation at least 4-8 weeks before surgery, early
mobilization, pre and post operative respiratory physiotherapy

to encourage deep breathing and provide intermittent positive

pressure breathing, and incentive spirometry.
Post operatively, adequate pain relief and an upright position
in bed should aim to ensure the patient is able to cough and
that the diaphragm is not splinted.

Principles of ordering a theatre list:

The main priority for list order is the clinical urgency of case. If
an operation is needed to save a patients life it takes priority
regardless of other issues.
Traditionally dirty cases and patients with MRSA are put last
on the list to facilitate adequate cleaning of the operating
theatre.
This is not always necessary provided the cleaning of relevant
surfaces can be done adequately before the next patient. After
the patient has left any surface the have come into contact
with should be cleaned with an approved detergent and hot
water. It should then be left to dry for at least 15 minutes
Diabetic patients should be placed early on the theatre list, to
reduce the chance of hypoglycaemia.
Summary of perioperative management of the diabetic patient:
There is no established consensus for optimal perioperative
management of diabetes, so the following is not a definitive
guide.
Diet controlled:
Diet controlled diabetics should not require any additional
precautions for minor surgery. Check the BM on the morning of
surgery, and intraoperatively.
If the BM is high, treat as for an insulin controlled diabetic.
Oral antihyperglycaemics:
Patients who are normally on oral antiglycaemics should stop
metformin 48h before surgery to reduce the risk of
lactic acidosis and stop sulphonylureas 24h before
surgery, to reduce the risk of hypoglycaemia.

For minor surgery omit the morning dose and monitor

the
BM
hourly.
For major surgery treat as for an insulin controlled
diabetic.
Insulin dependent:
For a patient on insulin you should admit to a ward 2-3 days
before surgery if Hba1C is >8% indicating suboptimal
control, or ideally they should be optimised in the
community before admission.
The patient should be first on the list.
Liaise with the diabetic team and anaesthetist.
Give a reduced bedtime insulin
hypoglycaemia whilst nil by mouth.

dose

to

prevent

Fast from midnight the night before, and place on an insulin5% glucose sliding scale regimen with hourly capillary glucose
measurement to allow optimum glycaemic control.
Check BM every 2 hours post op. This should continue
until they are eating and drinking after the operation,
at which time their normal insulin regimen can be
restarted.
If a diabetic patient has to be operated on in the afternoon
give the usual insulin the day before and allow them
breakfast at 07.30am. After breakfast they should be made
nil by mouth and be commenced on a sliding scale infusion
with hourly BMs up to and throughout surgery.

Abdominal Examination
On general inspection the patient is clearly in pain
On closer inspection she has no peripheral stigmata of liver or
gastrointestinal disease.
Her pulse is 90
Her respiratory rate is 18

There is no liver flap

You do not see any signs of jaundice
There are no lymph nodes palpable

On inspection of the abdomen there are no masses, it is not

distended, there are no scars or hernias present

On palpation the patient is in pain, particularly over the right

iliac fossa
Pressing in the left iliac fossa causes more pain in the right iliac
fossa than in the left iliac fossa (Rovsing's sign)
Murphy's sign is negative

There is no liver, spleen or kidney to be felt, and you can't feel

a expansile mass above the umbilicus

When you percuss in the right iliac fossa the patient squeals in
pain
There is no bladder palpable, and you can't detect any shifting
dullness
Bowel sounds are present

To finish my examination I would examine the external

genitalia, perform a digital rectal examination, and examine
the observation chart
Sarah Jones is a 20-year-old lady who presents with right iliac
fossa abdominal pain. On examination, she is clearly in pain.
She has no peripheral stigmata of liver or gastrointestinal
disease. On closer inspection of the abdomen, there are no
scars, and no obvious distension. She is very tender in the

right iliac fossa, particularly over McBurneys point but there is

no guarding. Rovsings sign is positive, Murphys sign is
negative. Her symptoms are consistent with appendicitis. I
would like to rule out an ectopic pregnancy.
The most important initial investigation is a serum or urine
beta HCG to rule out a ruptured ectopic pregnancy. I would
send bloods looking for raised inflammatory markers and might
arrange an ultrasound if I thought the diagnosis were
equivocal. Otherwise she needs to be worked up for an
emergency appendicectomy.
Guarding is the involuntary tensing of abdominal wall
muscles to guard inflamed organs within the abdomen.
Rebound tenderness is pain on removal of pressure
during examination of the abdomen, which represents
aggravation of the parietal layer of peritoneum.
Wash
your
hands
Introduce
yourself
Permission may
I examine you today please?
Exposure limbs, chest and abdomen should be exposed
Reposition The patient should be supine with their head
supported by a pillow
Ask the patient where their pain is
General inspection look around the bed for oxygen, IV fluids.
Gain a general impression as to how they are e.g. look in pain,
holding abdomen, increased respiratory rate.
Start at the hands
Inspect for stigmata of liver disease unlikely in this case, but
they include:
Palmar erythema, Dupuytrens contracture, spider naevae
Palpate the pulse, paying attention to rate and rhythm
Ask the patient to hold out their hands as if halting traffic,
testing for a liver flap (again not really relevant in one so
young)
Examine the mouth for the pigmentation seen in PeutzJeghers, and for aphthous ulcers seen in Crohns.
Look in the eyes for icterus (jaundice).

Make a point of feeling in the left supraclavicular fossa for

Virchows node.
When you get to the abdomen, inspect, palpate, percuss,
auscultate (IPPA)
Inspect for obvious masses, distension, scars, stomas, hernias,
and drains. Ask the patient to take a deep breath in, out and to
cough, then to lift head off end of the bed. This increases the
intra-abdominal pressure making hernias more obvious.
Check again for pain, and palpate in all 9 abdominal areas. You
should kneel down so that you are at the patient's level and
look at their face for signs of discomfort. First light palpation,
then deep palpation, feeling for masses.
As there is pain in the RIF, it is appropriate to test for Rovsings
sign palpation in the LIF causes more pain in the RIF.
Also look for Murphys sign laying a hand on the right upper
quadrant produces pain on inspiration, indicating an inflamed
gall bladder
Now palpate for a liver, starting in the RIF and working up. It
looks smoother if you then percuss for a liver.
Palpate for a spleen, again starting in the RIF, and palpate in
the same way.
Ballot for kidneys bilaterally, pushing up with the posterior
hand, a ballotable kidney is an abnormally large kidney
Place two open palms onto the abdomen either side of the
aorta, above the umbilicus, and feel for an expansile pulsatile
mass.
Percuss the tender area a kinder way to test for rebound
tenderness
Percuss for a large bladder and for ascites testing for shifting
dullness
Auscultate for bowel sounds
To finish my examination I would examine the external
genitalia, perform a digital rectal examination, and examine
the observation chart
Turn to the examiner, hands behind back and present your
findings