The clinical judgement station in the CT1 anaesthetics and ACCS interview is unusual: you see the scenario before you enter, you get five minutes to read it, and you can make notes and bring them in. Candidates who treat those five minutes as reading time rather than planning time give up the biggest advantage the format offers. This guide is about using them.
What is being scored
Three domains: clinical judgement and decision making, reflective practice, and working under pressure. The scenario is pitched at FY2 level and no anaesthetic knowledge is expected. The assessors are not testing whether you know the dose of adrenaline in anaphylaxis, though you should; they are testing whether you approach an unwell patient safely, escalate early and well, recognise the limits of your role, and can reflect on what happened and how you handled the pressure.
Every scenario therefore has the same four layers, and the five minutes are for writing them down.
The five minute plan
Minute one: read the scenario twice and identify the problem and the immediate danger. Write the diagnosis you suspect and the one or two you must exclude.
Minute two: the immediate actions in order. ABCDE, oxygen, access, bloods, monitoring, the specific treatment for the likely problem, and what you would ask the nurse to do. Write them as a list in the order you will say them.
Minute three: escalation. Who you would call, when, and what you would say. Write an SBAR handover in four lines: situation, background, assessment, recommendation, with the recommendation stated as what you want the senior to do.
Minute four: the second part of the scenario. The assessors will worsen it: the pressure falls, the patient stops responding, the registrar does not answer. Write what you would do for the two most likely escalations.
Minute five: reflection and pressure. Write two things you would reflect on afterwards and one thing you would do to keep yourself effective during the event. The assessors ask about both directly, and candidates who have not prepared them improvise badly.
The scenarios and their layers
The upper gastrointestinal bleed: ABCDE, two large bore cannulas, bloods and crossmatch, fluids then blood, stop anticoagulants, the major haemorrhage call when the pressure is 80 and he is drowsy, the gastroenterology and anaesthetic teams. Reflection: what the ward could have done earlier.
The drowsy patient in recovery with a respiratory rate of six: opioid toxicity until proven otherwise, oxygen, naloxone titrated, airway support, the anaesthetist who gave the anaesthetic, and the review of the prescription. Reflection: the handover from theatre.
The post operative patient who is tachycardic, hypotensive and oliguric: sepsis, bleeding or the leak, the sepsis six, the surgical registrar, and the critical care outreach team. Pressure: the ward is busy and the registrar is scrubbed.
The tiring asthmatic: the silent chest, the saturations on high flow oxygen, the nebulisers and the steroids, the gas, the anaesthetist and intensive care called early because this patient may need intubation. Reflection: recognising the tiring patient before the arrest.
The tenfold opioid error: the patient first, naloxone and monitoring, then the senior, the incident report, the duty of candour and the conversation with the patient, and support for the nurse.
Answering in the room
Say what you would do in the first person, in the order you planned, and say why. When the assessors worsen the scenario, go back to ABCDE rather than guessing; it is the safe answer and it is the one they are scoring. When they ask who you would call, give the SBAR you wrote. When they ask about reflection, give the two things you prepared and say how you would record them. When they ask about pressure, describe the one strategy you wrote down and give an example of it working.
The common failures
Reading the scenario and walking in with no plan. Giving a textbook management plan with no escalation. Escalating without a clear request. Claiming you would manage the patient alone. Having nothing to say about reflection. All five are avoided by using the five minutes to write the four layers.
Practising
Take the ten recurring scenarios, give yourself five minutes with each and write the plan, then deliver it aloud to someone who worsens the scenario and asks about reflection and pressure. Do it until the planning is automatic, because on the day the clock will be running and the assessors will be waiting.