The Care of the Critically Ill Surgical Patient course from the Royal College of Surgeons of England gives you a three-stage system for any sick surgical patient: immediate management using ABCDE, a full patient assessment, and then a decision to treat, investigate or escalate with a written plan. In the CST management and clinical station this structure is the answer. The scenario is a ward patient who is deteriorating, and the marks are for a safe, ordered response said out loud, not for a differential recited from a textbook.

How do I assess this patient?

Say the three stages by name before you start, because the panel is listening for the structure as much as the content.

Stage one: immediate management

  • Airway: is it patent, is the patient talking, is there stridor or a noisy airway. Open it, suction it, call an anaesthetist if it is threatened
  • Breathing: respiratory rate, saturations, work of breathing, chest examination. Give oxygen to a target range and reassess
  • Circulation: pulse, blood pressure, capillary refill, urine output. Wide-bore access, bloods, and a fluid bolus if hypovolaemic
  • Disability: AVPU or GCS, pupils, capillary glucose
  • Exposure: temperature, the wound, drains, calves, the abdomen, and anything under the blanket

The Resuscitation Council UK principle underneath this is simple: treat life-threatening problems before moving to the next letter, reassess after each intervention, and call for help early. If the patient is stable after stage one you move on. If they are not, you stay in stage one, escalate, and keep treating.

Stage two: full patient assessment

  • Chart review: the observations trend, fluid balance, drug chart, NEWS2 over the last 24 hours rather than the last set
  • History: the operation, the day it is post-operatively, the comorbidities, what changed and when
  • Examination: a systematic head-to-toe, not a repeat of ABCDE
  • Available results: bloods, gases, cultures, imaging, and what is still outstanding

Stage three: decide and plan

Either the diagnosis is clear and you treat it, or it is not and you order the specific investigations that will make it clear. In both cases the plan is written, the review time is stated, and the escalation is named: who you have told, and what would make you call again.

What are the key investigations and findings?

The panel does not want a list of every test. It wants the tests that change the decision in this patient. For most ward deteriorations that means a venous or arterial blood gas with lactate, full blood count, urea and electrolytes, CRP, clotting, cultures if infection is possible, an ECG, and a chest radiograph. Imaging of the abdomen follows the examination rather than replacing it.

What is the management?

Management in this station is the three stages themselves. Give oxygen to the BTS target of 94 to 98%, or 88 to 92% if the patient is at risk of hypercapnic respiratory failure. Resuscitate with a 500 ml crystalloid bolus over less than 15 minutes if the CG174 indicators of hypovolaemia are present, and reassess before the next. Then treat the cause you have found, or investigate to find it, and write it down.

When do I escalate and to whom?

Escalation is part of stage one, not an afterthought. A NEWS2 of 5 or more is the urgent-response threshold and 7 or more is the emergency-response threshold, and either should have you calling your registrar and, at 7 or more, the critical care or outreach team. Escalate earlier if the patient looks worse than the score, if you are not confident, or if a treatment has not worked within the time you set. Say the name of the person you would call and what you would say in one sentence.

What is the interviewer listening for?

  • The three stages named and used in order, with reassessment after each intervention
  • Numbers rather than adjectives: the saturations target, the bolus volume, the NEWS2 score
  • A named escalation with a reason, and a fallback if the first person does not answer
  • Recognition that a surgical SHO's job at 3am is to stabilise and call, not to solve everything alone
  • A written plan with a review time, so the next person knows what you expected to happen

What might they ask next?

  • The registrar is scrubbed and the consultant is not answering. What do you do?
  • The patient improves after one bolus. Are you finished?
  • What would make you move this patient to a higher level of care?
  • How would you hand this patient over at the end of your shift?

The Core Surgery Interview question bank has a scored scenario on the deteriorating ward patient: /Question-Bank/Sample-Questions.