Of all the clinical stems surgical selection panels use, the deteriorating post operative patient is the most reliable, because it tests everything a surgical registrar must do: recognise, resuscitate, decide, involve the right people, and talk to the family. It appears in general surgery SET interviews, in other SET specialties, and in surgical registrar appointments. This guide is about answering it well.
The stem
A patient three days after a right hemicolectomy has a heart rate of 130, a temperature of 38.5 and abdominal pain. What do you do?
Variations: the post operative patient who is breathless and tachycardic, the one who has not passed urine, the one whose wound is discharging, the one with chest pain. The structure is the same.
A structure that scores
- Go and see the patient. Say it. The panel wants to hear that you go now, not that you order tests from the phone.
- Assess systematically. ABCDE, the observations and their trend, the abdomen, the wound, the drains, the chart. Say what you are looking for: the anastomotic leak, the collection, the bleed, the pulmonary embolus, the pneumonia, the line infection.
- Resuscitate while you assess. Oxygen, access, fluids, blood tests including lactate and cultures, antibiotics if sepsis is likely, analgesia. Say the specifics.
- Investigate with a purpose. The CT with contrast for the leak or collection, the chest imaging for the embolus, and what you would do while waiting.
- Decide. This is where surgical registrar level shows. Say what you think is going on, how unwell the patient is, and whether they need theatre, intervention, intensive care, or observation. If you would wait for the CT, say what would change your mind before it.
- Escalate with a plan. Phone the consultant with the assessment and a recommendation, not a request for instructions. Involve intensive care early if the patient is deteriorating.
- Communicate. The patient and the family: what is happening, what you are doing, what might happen next. The nursing staff: the plan and the triggers for calling you back.
- Afterwards. The documentation, the handover, the morbidity and mortality presentation, and open disclosure if a complication is confirmed.
The probes
- The CT shows a leak. What now?
- The consultant is two hours away and the patient is deteriorating. What do you do?
- The family want to know whether something went wrong in the operation. What do you say?
- The patient refuses to go back to theatre.
- What would you do differently in the original operation or the post operative plan?
Prepare each. The family question tests open disclosure: honest, early, without speculation about blame, with the consultant involved. The refusal tests capacity and consent. The consultant two hours away tests whether you will act: the decision to take the patient to theatre with the on site consultant or the anaesthetist, the interim management, and the escalation to the head of unit.
What the assessors score
The RACS competencies that this station maps to are medical expertise, judgement and clinical decision making, communication, collaboration and professionalism. The top band decides, acts when help is distant, involves intensive care early, speaks to the family honestly, and reflects on the operation afterwards. The bottom band orders tests and waits.
Practising
Talk the scenario through aloud in about four minutes, then have someone throw the probes in random order. Do the same for the other post operative variations until the structure is automatic, because on the day you will have two minutes to read the stem and ten minutes under probing to deliver it.