Monday, 13 October 2014

Tutorial 13 October 2014

Viva. Risk management: Pelvic abscess post hysterectomy.
Roleplay. Teach a FY1 about shoulder dystocia.
Viva. Incomplete ECV audit.
Viva. Breast feeding.
Viva. Parvovirus.

25.  Viva. Risk management: Pelvic abscess post hysterectomy.
This is a fairly typical risk management question about a surgical case. You can put in whatever you like by way of the surgery and the postoperative problems: haematoma, bladder injury, bowel injury, pulmonary embolism etc.

Mrs. S. J, 48 years of age, was admitted for abdominal hysterectomy + bilateral salpingo-oophorectomy for fibroids. On admission she was noted to be healthy, but allergic to penicillin.
The surgery was performed by an ST3 assisted by a Foundation Year 2 doctor.
The theatre notes read:
“TAH + BSO. Pfannenstiel incision. Uterus enlarged by fibroids. Routine procedure. Vicryl to sheath. Clips to skin. Routine post-op care. Nurse discharge”.
The postoperative medical notes read: “
Day 1 review at 09.00 hours by the ST3 who performed the surgery:
“Op findings explained. Looks ok. Obs. satisfactory”.
Day 2 review at 09.00 hours by FdY2 doctor:
“Obs stable, remove catheter, allow oral fluids and take down i.v. line.
Pt c/o nausea, has not passed flatus”.
Day 2 review at 14.00 by Ward Nurse:
“I.v. line re-sited as pt unable to take orally and vomited x 1”.
Day 3 review at 09.00 by Consultant and ST3 who had not performed the surgery.
Pt febrile, vomiting, abdomen distended, has not passed flatus
Suspected ileus. Abdominal x-ray ordered”.
Day 4 review at 09.00 by ST3 who had performed the surgery:
 “Pt febrile, still vomiting and abdominal distension.
No bowel sounds. X-Ray not back as yet”.
Day 5 review at 09.00 by FdY2 who had assisted at the operation:
“Abdo distended with rebound tenderness, VE: mild
tenderness. For review by GS”.
Day 5 management and subsequent progress:
Patient seen by the general surgeons who take over her care. The x-ray report is tracked and is
suggestive of intestinal obstruction. Emergency laparotomy done by Consultant in general surgery that afternoon. Right-sided pelvic abscess, 8 cm. x 6 cm. with evidence of old haematoma. No bowel injury or damage to other organ. No evidence of active bleeding. Abscess drained, lavage done, i.v. antibiotics prescribed and pelvic drain left in-situ. Patient recovered well over next 10 days.
Your task.
You are an ST5. The case is being investigated by a Nursing Sister on behalf of the clinical risk management team for gynaecology. Your Consultant has been asked to produce a report, but has delegated the task to you, saying it will be useful experience for when you are a Consultant.
The Nursing Sister has produced a list of things she would like included in the report.
1.       is all the information needed for the report included in the above summary? If not, what additional information do you require and how should it best be obtained?
2.       do you need further statements and, if so, from whom should they be obtained?
3.       can you identify from the above any indicators of possible deficient care?
4.       are there any recommendations you can make relevant to the department of gynaecology and the other specialties in the hospital?
5.       the woman has lodged a complaint about her care and has indicated that she is likely to go on to sue the hospital. Is there anything that can be done to lessen the chance of litigation?

26    Roleplay. Teach a FY1 about shoulder dystocia.
         You are a year 5 SpR and have been asked to teach a new FY1 about shoulder dystocia.

27    Viva. Incomplete ECV audit.
Candidate’s instructions.
A colleague who has left the hospital was conducting an audit of ECV.
The audit is incomplete.
The data are:
    Consultant A offered ECV to one group of women and had an 70% success rate,
    Consultant B offered ECV to a different group and had a 30% success rate,
    Consultant C did not offer ECV at all.
Tell the examiner how you would go about completing this audit.`

28.   Viva. Breastfeeding.
Candidate’s instructions.
This is a viva station.
The examiner will ask you 6 questions.

29.   Parvovirus.
         Candidate’s instructions.
         This is a viva station.
         The examiner will ask you 22 questions!


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