Post-operative complications — structured oral station (12 minutes)

Opening prompt — "Tell me what you do from the doorway."

Model response — say it in this order: ^[2][4]

• "This is a NEWS2 score of 6 — that's an urgent response. I would call my senior now and ask the critical care outreach team to attend. I would go to the bedside, run an ABCDE assessment, and concurrently assign roles — a scribe, a runner, and a doctor to put in IV access."
• "I would establish IV access, take bloods including FBC, U&E, CRP, lactate, coagulation, blood cultures, and start broad-spectrum antibiotics within 1 hour — for an intra-abdominal source, piperacillin-tazobactam 4.5 g IV q8h plus metronidazole 500 mg IV q8h."
• "I would start fluid resuscitation with 30 mL/kg crystalloid if hypotensive or lactate ≥4, and apply vasopressors if MAP under 65 despite fluid. I would also insert a urinary catheter, place an NG tube on free drainage, and arrange CT abdomen and pelvis with IV and rectal contrast." ^[2][4]

Examiner is listening for: parallel action, named roles, the NEWS2 score and the action it triggers, the sepsis bundle, and the consultant call.

Probe 1 — "What is your working diagnosis and why?"

• "Day 5 post-op, tachycardia out of proportion, ileus, drain fluid change from serous to muddy brown — this is the classic presentation of anastomotic leak. The anastomotic leak peaks day 5-8, the peritoneum signs an early warning, and the drain fluid change is the late sign." ^[1]
• "The day-of-onset differential is the leading principle: day 1 = haemorrhage, day 3 = ileus and UTI, day 5-8 = wound infection, anastomotic leak, intra-abdominal collection, day 7+ = DVT, PE, hospital-acquired infection. I am running the day-of-onset logic, not just the differential." ^[1]

Probe 2 — "Her lactate is 4.5. What now?"

• "Lactate 4.5 is the threshold for aggressive fluid resuscitation per the SSC 2021 hour-1 bundle. I would give 30 mL/kg crystalloid, repeat lactate in 2 hours to assess clearance, and apply vasopressors if MAP under 65 despite fluid. The qSOFA — RR 22, SBP 102, mental state — is borderline but the SOFA + lactate define sepsis with end-organ dysfunction."
• "Sepsis-3 defines sepsis as life-threatening organ dysfunction from a dysregulated host response to infection; organ dysfunction is a SOFA score increase of 2 or more. Septic shock is vasopressor requirement with lactate >2 mmol/L." ^[3]

Probe 3 — "You have given the bundle and antibiotics. CT shows extraluminal contrast and a 6 cm perianastomotic collection. What is your next step?"

• "This is not source-controlled. The collection needs draining — given the size and location, I would contact interventional radiology for percutaneous drainage and call the surgical consultant to discuss the indication for return to theatre."
• "The criteria for surgical re-look are: peritonitis, undrained collection, failure to improve within 4-6 hours of resuscitation, haemodynamic instability, anastomotic dehiscence on CT, or progression to septic shock. This patient has an undrained collection and probable anastomotic dehiscence — return to theatre is the right answer, with options including peritoneal lavage, defunctioning ileostomy, and revision of the anastomosis." ^[1][4]

Probe 4 — "She is bleeding from the drain as well. What do you do?"

• "I would activate the massive haemorrhage protocol, give tranexamic acid 1 g IV over 10 minutes within 3 hours of bleeding onset (WOMAN trial), and continue the resuscitation with 1:1:1 ratio, fibrinogen replacement if under 2 g/L, calcium replacement, and warmth." ^[5]

Probe 5 — "The patient is frightened and asks if she is going to die. Her partner is at the bedside."

This is a scored domain, not a courtesy. Demonstrate it out loud: ^[1]

• Move to her eye level, use her name, brief plainly: "You have developed a complication after your operation. We have a team here, we are giving you antibiotics and fluids, and we are arranging a CT scan to find the cause. We will keep telling you what is happening."
• Acknowledge fear, keep the partner informed, allocate a staff member to support them, avoid jargon and conducting the conversation with your back turned.
• Commit to a debrief afterwards.

Probe 6 — "What will you do after she is stable?"

• Clavien-Dindo classification for documentation (this is IIIb or IVa depending on the course); morbidity and mortality review; VTE prophylaxis once bleeding is secure; safety-netting for discharge with named contact and criteria for re-presentation; follow-up in 4-6 weeks with histology review for malignancy; mental health check.^[6]