E117 Mock Orals by Elizabeth Clement at Alberta Association of General Surgeons (AAGS) Meeting
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Chad Ball 00:12
Welcome to the Cold Steel podcast, hosted by Ameer Farooq and myself, Chad Ball. We consider it an absolute privilege to bring you guests from around the world who are truly experts in their craft. Our mission is to offer you a combination of not only master classes on clinical surgery topics, but also insights into achieving personal growth, productivity, and fulfillment as a surgeon, and perhaps more importantly, as a human.
Ameer Farooq 00:43
Welcome, everyone, to a special episode of Cold Steel. We're very happy to put out this episode, which is another episode of mock oral exams. And we were quite lucky this time to actually be the beneficiaries of the AGS conference, which is the Alberta Association of General Surgeons conference, that was held back in November of 2021, this year. It's an annual conference that's held every year in Alberta. And as part of that conference, Dr. Liz Clement, who is actually one of the colorectal fellows here at UBC, and a former resident from the U of A program, put together a session of mock oral exams for a bunch of the senior residents who are attending AGS. As we really feel that it's, you know, as much practice as possible for these senior residents, it's just going to do them in good stead. And so, once again, thank you to AGS for allowing us to use their space, and some time during the conference, to do the mock orals. And thank you to Dr. Elizabeth Clement, for putting this all together, and really figuring out the logistics of everything, and making it happen, and allowing us to use some of the recordings of mock orals. And thank you to all the examiners, all the surgeons from both Edmonton and Calgary. Thank you to all the residents, as well, who volunteered to actually be recorded. You know, this is a very brave thing to do, to put your necks out there and be recorded, and also be examined when the stakes aren't really as high for them yet. You know, most of the residents that we have recorded are fourth year residents, so they're not in their fifth year, not really in the throes of their exams. But they're brave enough and really thoughtful enough to actually put themselves out there and go for it. I thought this would be a good time, Dr. Ball, to just go through some examsmanship techniques again, particularly thinking about the mock orals. What are some of the important tips and methodology tricks that you give to people when preparing for their oral exams?
Chad Ball 02:46
Yeah, thanks so much, Ameer, for the question. I agree, we should really thank the residents that were willing to put themselves out there to an international audience. You know, we intentionally, I think it's safe to say, have not overedited this in any way. We wanted it to be raw, we wanted, really, all trainees across Canada and elsewhere to think about how these resident candidate's answered questions, what they thought was good, what they thought was bad, where they thought they would improve. Really, the same process that each of the residents got, in terms of feedback. So really, kudos to them. You know, as far as organizing your thoughts and coming to an exam with a strong presentation and a really good performance, I would also encourage our listeners to go back to episode #10 of Cold Steel, and just revisit our interview that you and I did with Tony McLean, who was the current chief of the Royal College Examining Committee, here in Canada. Obviously, he didn't go through any specific scenarios, as of course he can't, but he did give us some pretty broad insights into examsmanship and what really matters. So, you know, a lot of my thoughts being trained by Tony long ago, and being around him every day, come from guys like him and preceding that, Don [inaudible], and other folks that have been involved with the Royal College for a long time. So, I think that the exam clearly has changed a lot over the years. It's quite focused, and I think one of the biggest surprises, probably, to candidates, and you could speak to this having done it not too long ago, Ameer, is they're relatively rapid pace and the focus nature of it, hey?
Ameer Farooq 04:31
You know, might as well get the jokes out there right off the hop. I actually was the special year that didn't have an oral exam. So yes, go ahead, say all your jokes about FRCSC-W. But yes, in even doing some of the, seeing how these oral exams are put together, or practicing them, they go by really fast. So, you really have to have an organized approach and a thought process on how you're going to attack these oral exams.
Chad Ball 05:00
Yeah, I think that's exactly right. You know, and in terms of things that probably set off, or are seen as negatives to the actual examiner, the first thing that comes to mind is just, be physically and verbally humble. Be respectful of the process, be uber respectful of the examiner's time, and their willingness to take, traditionally in Canada anyway, a week off work to go to the Ottawa facility and do these oral exams. You don't want to walk in with too much bravado, and certainly don't want to be interpreted as arrogant. So that's probably not a problem for most folks, but it certainly is for some. And then you're right. The second thing is really to be organized to present your thoughts in an organized, linear way, that shows that you really have prepared well. I think candidates that sort of jump around and seem a little bit confused, probably more than anything, that can certainly put off examiners. There's really no doubt about that. The reality, though, as you probably know as well, Ameer, is that the examiners are there to not only examine you, obviously, for content and knowledge, but they're there to help you. And the exam really has changed significantly in Canada to try and allow them, you know, if you do start to come off the appropriate pathway, to help nudge you back onto it. You know, they really are quite skilled at that, at a very high level.
Ameer Farooq 06:40
Dr. Ball, do you have any specific ideas or tricks that you give people to kind of get themselves back on track, if they start to come off the rails? You know, for example, some people are fans of summarizing the case, especially after you've had the history and physical component. Often, not every scenario is going to be like this, but often, you'll get the history in the physical and then you'll have to come up with a differential and a plan. I've certainly heard people talk about kind of summarizing the case. Are you a fan of that? Are there any other particular strategies that you tell people if they're getting confused? Or if they feel like they're losing track and focus during their scenario?
Chad Ball 07:26
Yeah, it's an interesting question. The summarization technique can be helpful, I think, to buy you time and organize your thoughts a bit and show some organization to the examiner. But you certainly don't want to perseverate on it. And that's probably for two reasons. One is, again, the exam does have to move forward relatively rapidly. So, you don't want to waste anybody's time, i.e., the examiner's time. The second thing is you certainly don't want to provide an overly long summary. You want to, more to the point, show you've been listening, show you're engaged, show you've assimilated that information, but I certainly wouldn't spend too much time on it. Two things come to mind, maybe in closing. The first is that my recommendation to anybody, particularly if you're doing fellowships in the US, is to do the American board exams as well. And there's lots of different reasons for that. But one is, to be truthful, it's really quite fun in the process on the oral side, the oral examination side, is very, very different. And the experience is very different. Their exam is certainly dictated by areas and domains that they have to ask you about. But it's much more of the Wild West, and it's much more an exam like Canada used to be. And really, that does highlight the structured, reasonable nature of the Canadian exam, there's no doubt. The other thing I would say is that a lot of people, whether they are naturally verbally strong, or good at presentations, for example, at research meetings, don't necessarily examine well. And I would say that I was probably in that descriptor at my stage as a resident, as well. What's great, though, and what the reality is, that shouldn't hold anybody back, and it shouldn't discourage any trainee. You can get as good as you need to and become infinitely better just by practice. So, grab your local faculty, grab recent graduates, grab your fellows, grab anybody you can, and just keep practicing. Start early, try and do it, don't leave it to the last three or four months. Work on it gradually. As you can see, as you'll hear, I should say, these fourth yea residents that did this did a marvelous job and thinking back to it, I think they're far ahead of where I was in terms of examination skills in my fourth year. So don't be discouraged. The content will come with work and effort. But it's really the process and the examsmanship skills that I think are not natural to a lot of us, but can be learned just by drilling over and over again.
Ameer Farooq 10:19
The one editorial note, I'll also make, Dr. Ball, is that I feel like in preparing for the exam in general. First of all, you benefit again, so much from just reading cover to cover these textbooks, really getting into the minutiae of this data. And it's surprising how often, you know, you'll see some crazily, what you thought was such a minutiae-type, esoteric, fact show up in real life. Zuska's disease, some breast disease that I thought I would never see in real life. And yet, one day on call, you'll see it. So that's one thing is that the exam really does help shore up your knowledge. And I think in particular, for the oral exam, it's funny how, you rehearsing for the spiel that you're going to give. This is how I would do a trauma laparotomy. It's funny how that mantras and those scripts that you ran in your mind for the exam, suddenly appear and bubble up through the surface of your mind when you're actually faced with a real-life scenario. And you're suddenly like, "Okay, what do I need to do?" And your adrenaline is kicking in and you're feeling that fight or flight reaction, you can't remember anything. Suddenly, these scripts start to bubble up through your mind. So, you know, I really do think, beyond the exam, I think the studying that you do for this is really quite beneficial. It's not like many of the exams you've taken up until this point where you memorize things, and then you forget them. These things really do matter and are very helpful.
Chad Ball 11:47
It's important to just make one disclaimer, that we are not officially affiliated with the Royal College exam. And these are simulated scenarios and may not represent exactly the type of format that you might see on the Royal College. And really, these are more about getting familiar with the mock world scenario, and style, as opposed to precise content from the series.
Elizabeth Clement 12:32
So, you're referred a 40-year-old who's recently found to be BRCA positive, she's unsure what this means. And we'd like to know about her risk of cancer. So, what are you going to say to her?
Resident #1 12:45
So, I'd tell this young woman, who was recently found to be BRCA positive, that she carries a gene that increases her risk of developing breast cancer, in addition to other cancers like ovarian cancer as well. It doesn't mean that she will develop cancer for sure, but this is something that runs in her family and her risk of developing cancer is higher than the general population risk of ovarian cancer.
Elizabeth Clement 13:19
Then you mentioned, did you say anything about percentages, or do you know that?
Resident #1 13:23
I didn't say anything about percentages. I will let her know that because of the fact that she's BRCA1 positive, she'll have to start screening for cancers at an earlier age. I'll have to look up the percentages.
Elizabeth Clement 13:36
Okay, so you've talked to her about the risk, and now we're going to tell her about options for this risk reduction. So how are you going to counsel her on what to do next?
Resident #1 13:53
Okay, so in terms of risk reduction for breast cancer for her, I would counsel her that we would recommend that she starts screening at an earlier age than general population for the development of breast cancer. We would use the usual modalities including screening mammography, screening for breast cancer and the other option that would be available to her, given that she is a high risk, would be prophylactic surgery to reduce her risk of developing cancer in the future. Okay, sorry. So, what surgery should she have? A prophylactic bilateral mastectomy.
Elizabeth Clement 14:41
Okay, so those are your options, surgery or surveillance. Okay, so now what do you tell her if she says, "What's my best option?" What do you say?
Resident #1 15:04
I would tell her I would have to consult with one of my breast surgery colleagues who sees this more regularly, to tell her which option is better. And that it would be a personal choice for her, if she was willing to have the risk undergo the risk of having a prophylactic bilateral mastectomy, would be reasonable and I would suspect equivalent to having screening for breast cancer and then dealing with a malignancy if that arises and we could catch it early with our shortened screening intervals.
Elizabeth Clement 15:47
Okay, so let's say. After all this, she settles on surveillance, she's followed at the high-risk clinic and she's good. She goes, she's adherent. She declined any kind of prophylactic bilateral salpingo-oophorectomy. She also declined tamoxifen, that you didn't mention, but just keep that in mind for later. She wants another child, so she doesn't want to have that stuff. Okay, so then you see her in clinic after three years. And then now there's a lesion that's found in the right breast. So now you do this whole workup because there's the lesion. So, she's got a T2 lesion, ER-positive, invasive ductal cancer. There's no lymphadenopathy. Okay. So, what are you gonna recommend now? Surgery and what?
Resident #1 16:30
So, I have a 43-year-old lady, now, known BRCA1 mutation that has a T2 hormone receptor positive invasive ductal carcinoma on surveillance. I suspect that it says the workup is complete, so her staging has been completed as well.
Elizabeth Clement 16:46
Correct.
Resident #1 16:47
No evidence of axillary disease. I would recommend that she undergo a mastectomy with a sentinel lymph node biopsy to stage the axilla, as well as a prophylactic contralateral mastectomy, to reduce the risk of contralateral breast cancer in the future.
Elizabeth Clement 17:07
Okay. So that's the end of that one, I think we've covered all of that. Do you feel good? Don't be nervous, it's okay. You're doing okay. Let's go to the next question, okay? Forgetting about breasts now, you're done. You saved her life. Okay, this is a little more, we'll take some time to read through, okay? So, a 65-year-old male, he comes in with right upper quadrant pain and jaundice. He's got a temp, heart rate's up, blood pressure 99/65, white cell counts are elevated, ALP is elevated, his bili is up. The lactase is normal, his lactate is two and a half. So, they did an ultrasound. Ultrasound shows there's a dilated extrahepatic duct and they're wondering about a stone. You've got atrial fibrillation, a history of peptic ulcer disease. Okay, he's had previous enterectomy with Roux-en-Y. He's on beta blocker. Okay, so let's think about your management. This is how he presents. So, you've just went down to see him.
Resident #1 18:13
So, I have a 65-year-old gentleman who is presenting with fever, jaundice and right upper quadrant pain, as well as hemodynamic instability with tachycardia and hypotension. I would make sure that he's on appropriate monitors, including O2 saturation and a blood pressure cuff that cycles regularly. I'd make sure he has two large bore IVs, I would start him on crystalloid fluid resuscitation with one liter of Ringer's lactate and then a maintenance of Ringer's lactate at 150. I would also start him on broad spectrum antibiotics with piperacillin-tazobactam to address his cholangitis. He does not have an elevated lactate and does not have any evidence of enteric disfunction so I hope that this resuscitation will hope address some of this instability. The past medical history of note is his previous Roux-en-Y reconstruction. Which would make doing what sounds like a choledocholithiasis with extra hepatic duct dilatation more challenging because he would not be amenable to a straightforward EOCP. So once I've managed to start him on a broad-spectrum antibiotic, fluid resuscitate him, I would plan for an OR. I'd do a common bile duct exploration. Either trans gastric or trans cystic. I suspect he still has his gallbladder though.
Elizabeth Clement 19:42
Yes, yes. No. Yes. Yes. He still has his gallbladder, sorry, yes.
Resident #1 19:46
He has his gallbladder, and he has common duct stone with ascending cholangitis. Does he stabilize with my resuscitation?
Elizabeth Clement 19:55
He, he stabilizes. Let me just see, let me just go to the next slide. Yeah. Okay. Yeah, he stabilizes.
Resident #1 20:05
He stabilizes. So, then my options are, we have to deal with this stone. Do we have ERCP available? Or someone that can do advanced ERCP procedure like rendezvous or something?
Elizabeth Clement 20:21
Yes. Yeah, you have access to these things.
Resident #1 20:24
And do we have IR available?
Elizabeth Clement 20:26
Yeah. Okay, so if he didn't resuscitate, he wasn't resuscitating very well, then...
Resident #1 20:35
Then I would take him to the operating room. Or sorry, I would take him to the IR suite for a PTC and drainage of his biliary system.
Elizabeth Clement 20:42
Yeah. Okay. Okay. So, let's say let's, let's move on. So, also, consideration of ICU. Okay. So, let's say this is what's happening now. I've changed direction. You've started resuscitation. He's on pip-tazo. You don't actually have access to endoscopy. But I had to get you to say all those things, anyway. It's important to say that. But you have IR to do that PTC. You did mention that. And they agreed to do this if you can correct the patient's coagulopathy. Because it turns out, he has a blood thinner. Forget to tell you that part. The guy didn't tell you, right? Patients forget this all the time. So now his INR is two and a half. Okay, so he does take a blood thinner. So now what are you gonna do?
Resident #1 21:27
So, I have a hemodynamically unstable patient who is anticoagulated with an INR of 2.5 and he needs an interventional procedure. So, I would reverse him more acutely with FFP. And I would start by ordering two unites of FFP and have them running on his way to IR to receive his PTC.
Elizabeth Clement 21:48
Okay, good. Okay, so they're going to take him to ICU because he's still not doing so great. But that's okay, you correct the INR, and then they do the PTC. And they decompress the biliary cheek. Good job, they did everything, but they can't get past the stone. Doesn't matter, the patient improves, okay. And then, hang on. I don't think, there's no question here, just letting you know what's happening. So, you're going to do a repeat cholangiogram. You looked at a lot of cholangiograms?
Resident #1 22:25
Um no.
Elizabeth Clement 22:25
Okay, well, here's what we're going to do, we're gonna look at the cholangiogram. I can try to make this bigger if you like, but let's see this. Well, I might wreck it, but let's see if that works.
Resident #1 23:20
That's okay, I can see it.
Elizabeth Clement 23:29
Okay, you could see it, but now I've messed it up. It gives us a break. Okay.
Resident #1 23:39
So, now my options are surgical removal of this stone. So, my options are either laparoscopic or open. Common bile duct exploration. My laparoscopic options are either trans gastric or trans cystic. And my open option would be open common bile duct exploration and stone extraction.
Elizabeth Clement 24:01
Okay, let's see. I think you're supposed to. Okay, so. Okay. So, we're waiting until the patient is stable, right? You had said that, I think? Maybe you didn't. Maybe you didn't say it but that's okay. That's what you would normally say. You can wait till they're stable. We're okay. Don't worry, we're good. They don't have any abdominal pain anymore, but we know that you need to take him to the OR. So, let's just describe the procedure. This is your open common bile duct...
Resident #1 24:11
Maybe I didn't. So, I position them supine, with both arms out. I'd give them appropriate preoperative antibiotic therapy, SCD stockings and pad all bony prominences. Prep abdomen in the usual sterile fashion. Start by doing an upper midline laparotomy and place a fixed retractor, like in Omni retractor. I would then start with exploring my right upper quadrant and begin with an open cholecystectomy. Once I've completed my cholecystectomy, I would identify my common bile duct and my porta hepatitis to allow for appropriate mobilization and exposure before I begin my common bile duct exploration. Once I've isolated my common bile duct, I would make a vertical choledoctomy and extract the stone, if possible, using Fogarty catheters. If I am able to extract the stone, then I will...
Elizabeth Clement 25:34
Okay, Fogarty doesn't work. What else can you, give me some other way to get the thing out.
Resident #1 25:39
I'll try to flush it down. I'll give them glucagon to see if that can help. In addition to the flush, to help push the stone down. Fogarty doesn't work. I can't...
Elizabeth Clement 25:55
Okay, I just wanted you to give me some other methods. So, that's good. Okay. Let's see. This is just a little bit more here. So, you couldn't get the stone out. Okay, still get stuck. So, it feels impacted. What are you going to do now?
Resident #1 26:09
So, a stone that's impacted at the ampulla. I would do a transduodenal sphincteroplasty. For this patient, I would, if I was in a center that I had access to a hepatobiliary surgical team, I would ask them to come in for an intraoperative consult to help with this procedure, because it's something that I haven't done before and I'm not comfortable with. If I didn't think I was able to do it, and the hepatobiliary surgery team was not there, then I would repair my choledocotomy over a T tube, knowing that I have proximal drainage of my PTC. And I would send them off to a tertiary center for hepatobiliary management. Okay, how do you make the duodenotomy? What's the direction or describe how you would do it. I know you said you haven't done it... No problem.
Elizabeth Clement 26:54
But just go through the steps of how you would do it.
Resident #1 26:57
It would be a transverse duodenotomy and I would close it, in the opposite, the horizontal duodenotomy that I would close transversely to reduce meiosis structure there.
Elizabeth Clement 27:11
Okay and where's the choledochotomy that's done inside there? Okay, I tried, just getting you there. All right, so we are going to start with question one. So, you were called to the emergency department for a 25-year-old male brought in by EMS. After he sustained a stab wound to his left chest, around the eighth rib. He is intoxicated, what is your initial management?
Resident #2 27:55
ABCs. So, examination of the patient. Is the airway open? Is he able to talk or not? While we're doing ABCs, I'd ask the nurses to get two large bore IVs, hook him up to monitors and oxygen. When I look at his airway, does he have an airway?
Elizabeth Clement 28:10
Yep, he's awake. He's talking.
Resident #2 28:12
Do the circulation. So, on the left side of the chest, eighth rib, we have spleens and lung. Is there an exit wound that we see, or no? And there's no obvious gushing blood anywhere else?
Elizabeth Clement 28:30
No.
Resident #2 28:34
So, I would want to finish the ABCs. Get those lines and get him on the monitors. Do a full head to toe exam, just quickly, making sure there's no other missed injuries of the extremities, like long bones. Do a log roll, check his back, see if there's another injury that we've missed. And then get a chest X-ray in the trauma bay.
Elizabeth Clement 28:58
Okay, anything else?
Resident #2 29:02
Get a CT, he seems stables, do we see any signs of auscultating in his lungs. Are we hearing breath sounds on both sides?
Elizabeth Clement 29:13
Yeah, so you get him on the monitors. Your vitals are as follows, his heart rate is 120, his blood pressures is 125/75. Sating 98% on three liters and his GCS is 14. You find a single stab wound to the left anterior axillary line at the level of the eighth rib. Your fast is equivocal, and your chest X-ray shows a left sided hemothorax. What is the next step in your management?
Resident #2 29:37
Place a is the chest tube on the left side for the hemothorax.
Elizabeth Clement 29:40
Describe how you're going to do that.
Resident #2 29:41
So, the patient is still maintaining his own airway. Line him supine while all of the material is getting ready. Anesthesia should be in the room. Localize the area. So, if we're aiming for anterior axillary line, fourth intercostal space. So, anesthetize him, make a vertical incision following the rib line. I'd use Kellys to palpate overtop of the ribs, enter just directly overtop of the ribs, avoid the neurovascular bundle. And then, pop into the pleural space with the Kellys. Replace the Kelly with a finger and do a finger sweep, 360 degrees, to show there's no lung stuck up to the pleura. And then place a large bore chest tube into that [inaudible] aiming [inaudible] and then open the chest tube, put it on suction.
Elizabeth Clement 30:37
Great. So, you do that, you get 300 ccs of blood back right away. Then it slows down. Your patient's vitals improve. Heart rate 105. Trauma labs are all normal. You're, sorry, your hemoglobin is 145, lactate is 2, alcohol level 24. What is the next step in your management?
Resident #2 31:00
So, I'd want to put him on antibiotics and give him a tetanus shot. And then, in terms of, do we have any additional information from police or EMS about what had happened? Nothing more. Just the alcohol level. So tox screen. In terms of just the area of this, because it's a little bit lower, I would want to take him to the CT scanner, as long as his heart rate has improved and he's still maintaining his own airways. I'd take him to CT scanner for chest and abdomen, pelvis CT scan with contrast.
Elizabeth Clement 31:33
Okay, so you do that. And all you see is a residual small hemothorax. The patient's vitals are stable. There is some free fluid in the left upper quadrant, the chest tube has slowed down. What is the next step in your management?
Resident #2 31:47
Free fluid in the left upper quadrant. So, there's free fluid in the left upper quadrant, I would be concerned that there was a transition of this penetrating injury across the diaphragm, potentially to the spleen. So, I'd want [inaudible] for laparoscopy at the minimum, with the potential to open [inaudible].
Elizabeth Clement 32:03
So, you do that. You see blood in the left upper quadrant, with active bleeding. You note a two-centimeter hole in the left dummy diaphragm and you notice an injury to the stomach on your laparoscopy. What's your next step?
Resident #2 32:17
So, if I had the skill and felt confident with a laparoscopic surgery of the diaphragm. I say laparoscopic but most likely open. Do a full trauma laparotomy just to make sure that we haven't missed anything else. So, exploring all four quadrants, making sure that there wasn't an injury to the spleen on that side, that we couldn't see. And then, in terms of the perforation or the hole in the stomach, depending on where it was, if it was really close and really lacerated or if it's just an in and out type of injury [inaudible] omentum.
Elizabeth Clement 32:59
So, it's on the greater curvature of the stomach and what you see is on the interior wall. Is there anything else you want to do?
Resident #2 33:05
I would check the posterior wall.
Elizabeth Clement 33:05
How are you going to do that?
Resident #2 33:09
So go into the lesser sacs and check posterior walls. If it reached the posterior wall, I would worry about the pancreas.
Elizabeth Clement 33:23
Okay, so you explore the lesser sac you see both an anterior and posterior injury to the stomach and you see a hematoma and pancreas. How are you going to manage these injuries?
Resident #2 33:33
Is the hematoma going across the ducts or is it a full...?
Elizabeth Clement 33:38
It's just in the tail of the pancreas.
Resident #2 33:41
[inaudible] the main ducts [inaudible]. If I wasn't confident about that [inaudible].
Elizabeth Clement 33:53
Is there anything else you can do?
Resident #2 33:56
I could leave a drain and have him get an MRI postoperatively to rule out a [inaudible] injury, sorry a main duct injury.
Elizabeth Clement 34:13
How are you going to repair the stomach?
Resident #2 34:15
So absorbable sutures, close the hole and patch it [inaudible].
Elizabeth Clement 34:23
And how are you going to repair the diaphragm?
Resident #2 34:25
The diaphragm, non-absorbable sutures, depending on how far we've [inaudible] try and reattach the diaphragm to the ribs or suturing the [inaudible] closed after [inaudible].
Elizabeth Clement 34:46
Okay, so you fix that, you close him. You leave a drain for the pancreas. He's doing fine, chest tube's out. On postop day 5, he becomes febrile and tachycardiac, complaining of abdominal pain. What is your management?
Resident #2 35:03
So, if he's hemodynamically stable and holding his pressures, I would want to get him to a CT scanner again. If he's not hemodynamically stable, then back to the OR to control the bleeding.
Elizabeth Clement 35:13
So, your scan shows a left upper quadrant collection which you percutaneously drained, anything you're going to check for?
Resident #2 35:19
Lipase anomaly.
Elizabeth Clement 35:22
Alright, so let's move on to the next question. So, you are working in a peripheral hospital, you're called to the emergency department at two in the morning to see 58-year-old male with hematemesis. Started at 6pm that evening. It seems to be getting worse. He's feeling syncopal. His past medical history, he's on Warfarin for atrial fibrillation. He's recently been using a lot of NSAIDs for back pain. Initial heart rate is 120, blood pressure 100/60, hemoglobin is 80 and his INR is 2. He looks pale, but he's not [inaudible]. What is your initial management?
Resident #2 35:54
Initial management will be resuscitation. So, give him a litre of crystalloid and screen him. I don't know how accurate that hemoglobin is. In terms of his INR, we could give him FFP. I don't know if this community hospital has access to OptiPlex. But if it's accessible, we can give it. Differential says we're assuming, or most likely, differential [inaudible]. Potential, various things you'd worry about. You'd worry about peptic ulcer disease, duodenal laceration. Do we have other medical history from him? Do we know what he was doing in the past couple days?
Elizabeth Clement 36:42
Just the FIP on warfarin and the NSAID use for back pain.
Resident #2 36:46
Was he vomiting before he had hematemesis?
Elizabeth Clement 36:48
Started at 6pm with hematemesis.
Resident #2 36:50
Just started at 6pm, okay. I would see if we had endoscopy available at that hospital.
Elizabeth Clement 37:00
Anything else you want to do before that?
Resident #2 37:09
Is it possible there is blood coming out? [inaudible] in the facility?
Elizabeth Clement 37:14
Okay, so you gave him blood. And so, you give them OptiPlex, you give him four units of uncross matched blood. They stabilized with respect to heart rate and blood pressure. And you give him a dose of erythromycin. So, you are the only person there, so you take him to endoscopy. And in D1, you find this. What is your plan?
Resident #2 37:48
So that doesn't look like there's an active bleed there.
Elizabeth Clement 37:55
No, it's visible. There's visible vessel... I don't know how that transmits, but...
Resident #2 38:02
See if we could inject it with epinephrine to stop the bleeding. If I could see an actual vessel coming out at me, then I could try to anastoclip it. I'd want to take biopsies of the area as well, because we're there.
Elizabeth Clement 38:22
Okay, so you clip it, you inject it. The patient actually settles. They do well overnight. But then, overnight, in the next morning, you find that their hemoglobin dropped to the 60s. You give them blood, you resuscitate them. You take them back to endo and you see an active bleeding vessel that you cannot control. The patient is now tachycardic, dropping their pressure. You are at a site that does not have interventional radiology. What is your plan?
Resident #2 38:48
So, we don't have [inaudible], should we go to the OR for a laparotomy? See if we can access the vessel [inaudible].
Elizabeth Clement 39:01
So okay, so describe your approach in the OR. There's no blood visible in the belly.
Resident #2 39:05
After my laparotomy, we could mobilize the stomach, and then feel the duodenum. See if we can feel that area that has a hematoma in it.
Elizabeth Clement 39:22
Any specific maneuvers you're going to do? In the first portion of the duodenum.
Resident #2 39:33
We could fully mobilize the duodenum. So, if we took down the [inaudible], dissect it along the duodenum to lift it up. Ideally, mobilize it so we can get better visualization.
Elizabeth Clement 39:48
So, all the blood is intraluminal. So, what's your next step?
Resident #2 40:05
Take the anterior wall of the duodenum and make an incision along it. And then we'll be able to better visualize where the bleeding is coming from.
Elizabeth Clement 40:13
So, you do that. You make a longitudinal duodenotomy and you see just blood.
Resident #2 40:21
I'd do suction and compression to try to locate the exact area.
Elizabeth Clement 40:27
So, you see the ulcer. You see the visible vessel, it's there, it's bleeding, you're in control of the bleeding. So, is there anything you can do to definitively manage that?
Resident #2 40:37
Definitively manage the bleeding,
Elizabeth Clement 40:38
This visible bleeding ulcer.
Resident #2 40:41
Okay. Other than resecting it?
Elizabeth Clement 40:45
Other than resecting it.
Resident #2 40:47
Can we inject with EPI now that we can see it?
Elizabeth Clement 40:50
See you do that, but it's still bleeding.
Resident #2 40:54
[inaudible] aren't working. Okay.
Elizabeth Clement 40:56
Okay, so you actually end up putting in some new stitches above and below. And then the patient becomes jaundiced on post-update 2. What are you going to do? We'll just finish this question.
Resident #2 41:08
[inaudible] stitches, I'd be afraid that we might have gone through the posterior side and caught the common bile duct in that [inaudible] and then basically constrict the common bile duct.
Elizabeth Clement 41:35
Okay, so how are you going to manage? They're jaundiced, their bilirubin's 100.
Resident #2 41:39
So, I'd want, if I'm in a spot where I could get a PTC, we can drain it externally. If we can transfer them to hepatobiliary, because they will eventually need hepatobiliary reconstruction. The PTC would buy us time for draining their [inaudible]. Get PTC and transfer them to hepatobiliary. Because I don't think you'd be able to go through endoscopically and stent it open if it was a stitch.
Elizabeth Clement 42:08
Yeah, okay. We'll end the question here. Generally, you're gonna stitch with dissolvable sutures.
Resident #2 42:15
Okay.
Elizabeth Clement 42:15
So, they will dissolve.
Resident #2 42:17
They will dissolve.
Elizabeth Clement 42:17
Yeah.
Ameer Farooq 42:21
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