Patient blood management — structured oral station (12 minutes)

Opening prompt — "How would you prepare this patient for surgery?"

Model response — say it in this order: ^[2][3]

• "I would confirm the iron deficiency with ferritin under 30 µg/L and TSAT 10% — this is the diagnosis, not just 'anaemia'. I would treat the cause as well as the consequence, by managing the menstrual losses with tranexamic acid 1 g PO q6h, mefenamic acid 500 mg PO q8h, or ulipristal acetate until surgery."
• "I would give IV iron now — ferric carboxymaltose 1000 mg IV over 15-30 minutes, single-dose regimen. Oral iron is too slow for surgery in 4 weeks. I would also consider EPO 300-600 U/kg SC weekly with iron cofactor."
• "I would recheck Hb at 2-4 weeks post-infusion to confirm response. If Hb remains under 80 g/L in this elective setting, I would consider deferring surgery by 1-2 weeks or proceeding with allogeneic blood products declined and autologous cell salvage optimised." ^[3]

Examiner is listening for: the iron diagnosis, the IV iron dose and rationale, the cause treatment, the recheck plan.

Probe 1 — "What is your transfusion threshold?"

• "The restrictive threshold is Hb under 70 g/L in a stable euvolaemic patient, supported by the TRICC trial (1999) and confirmed in subsequent trials — TRISS in septic shock, Villanueva in upper GI bleeding. In active bleeding or acute coronary syndrome, the threshold is higher, around Hb under 80 g/L." ^[1][6]
• "Liberal transfusion is harmful — the Docherty meta-analysis showed that liberal transfusion in cardiovascular disease and non-cardiac surgery increases mortality and infection."

Probe 2 — "She declines allogeneic blood. How does that change your plan?"

• "Patient blood management is the standard of care for her. I would document the consent with each component separately — allogeneic red cells, platelets, FFP, cryoprecipitate, fibrinogen concentrate, and autologous cell salvage. The consent must specify each fraction separately, not a generic refusal." ^[2]
• "I would set up intra-operative cell salvage with a leucocyte depletion filter before skin incision; the SALVO trial showed benefit in massive obstetric haemorrhage subgroup and the technique is reasonable in any patient at risk of significant blood loss." ^[4]
• "I would give tranexamic acid 1 g IV over 10 minutes within 30 minutes of skin incision; the WOMAN trial principle — 1 g IV within 3 hours of bleeding onset — applies to surgical blood loss as well as obstetric." ^[5]
• "I would set a permissive anaemia plan: lowest acceptable Hb, decision point for ICU, decision point for hospice care if transfusion declined at end of life."

Probe 3 — "What about post-operative management?"

• "I would continue IV iron or oral iron for 3 months to replenish stores. Ferritin recheck at 4-6 weeks; re-dose IV iron if ferritin remains low."
• "I would resume VTE prophylaxis once bleeding is secure — haemorrhage and tranexamic acid do not grant VTE immunity."
• "I would discharge with a written, named contact and criteria for re-presentation; planned follow-up in 4-6 weeks."
• "I would debrief her on the consent, the autologous cell salvage, and the outcome." ^[2]

Probe 4 — "She says, 'I don't want any blood products but I want to live.' How do you respond?"

This is a scored domain, not a courtesy. Demonstrate it out loud: ^[2]

• Move to her eye level, use her name, brief plainly: "Your wishes are at the centre of this consent. We will respect your refusal of allogeneic blood products and document each component separately. We will use every tool we have to optimise your blood — IV iron, EPO, cell salvage, tranexamic acid — to make surgery safer. If something unexpected happens, we will talk with you about your options."
• Acknowledge the conflict she is naming, name the team supports, commit to a pre-arranged plan with her and her family.
• Document the conversation contemporaneously with named witness.