Compiled by: Png Wenxian

PROCEDURAL SKILLS AND OTHERS

CHEST TUBE INSERTION
Clinical skills: Pneumothorax
24F for pneumothorax
28F for drainage of fluid/blood
insert chest tube, safety triangle?
Lateral border of the pectoralis major
5th intercostals space (level of nipple)
Mid axillary line.
Normally chest tube done in 4th or 5th intercostals space anterior to mid axillary line.
Because on forced expiration the diaphragm can rise as high as the 4th intercostals space.
what nerves?
Inserted in anterior to mid axillary line to avoid the long thoracic nerve which supplies the serratus anterior.
Inserted just above the border of the rib to avoid the intercostals nerves and vessels that runs at the inferior
border of the rib.
[2]

FNAC
clinical skills: FNAC - melanoma post op, now new swelling
give LA and aspirate and smear on slides
used the wrong needle, should use green needle
It is a procedure to investigate superficial lumps or masses.
Cells obtained after being stained examined under the microscope.

how long result take?

Should be immediate.
Experienced pathologist should be at bedside.
If sample not conclusive or inadequate, to repeat FNAC.

BOOD CULTURE AND IV CANNULATION

Blood culture [2]

Blood culture taking according to the NHS protocol (my friend who studied in RCS said: alcohol wipes, no
touch technique, change needles and alcohol wipe the bottles)

PREPARATION:
FILL UP BLOOD FORMS FIRST!
1. Greet patient.
2. My name is Dr Png. I am the doctor here. You have a temperature, you will need to take a blood test
via a blood culture. This involves taking 2 bottles of blood. But you do need it. Would it be ok if i
proceed?
3. Check name, ID, NHS number, date of birth. Compare with wrist band and consent form

Prepare equipment
4. Hand washing
5. Clean trolley, clean white box, clean sharp box.
6. Paste hazard bag on side of trolley.
7. Put on gloves.
8. Open pack, check bottles. Check clarity, expiry date. Mark out 10mls.
9. Take tourniquet.
10. Take out scrub/disinfectant
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11. Take out bottle wipes

12. Open needle and vacutaner. Connect needle to vacutaner.
13. Prepare any other blood bottles if needed. Lactate bottle needs ice.
14. Prepare tape.

Procedure proper
1. Wear apron
2. Wash hands with alcohol swab
3. Apply tourniquet, identify suitable vein
4. Clean and sterilize site with scrub/swab. Do it at least for 30s. Leave it to dry after.
5. While skin is drying, prepare bottles.
6. Open bottle caps. Clean the head of each bottle for 30s as well.
7. Take blood with butterfly, tape butterfly down.
8. Fill up blue aerobic bottle first. (This avoids introduction of air into the anerobic bottle)
9. Invert bottle a few times to mix with broth
10. If lactate tube needed, take blood without tourniquet applied.
11. Place lactate tube in ice and send off immediately.
12. Butterfly has safety device to prevent needle stick injuries.
13. Throw needle immediately into the sharp bin.
14. Thank patient
Post procedure
15. Dispose waste in clinical waste bags, sharps in sharp box.
16. Remove gloves and sipoase in waste bag
17. Clean the trolley
18. Wash hands
19. Ensure that the bottles are labelled
20. Document the procedure in the patient’s notes.

[4] Setting IV cannula, taking bloods, connecting up the IV infusion set for a hypotensive patient. This actor
was damn irritating kept asking if he needed surgery or if he was going to die, while I was trying to cannulate
the mannequin limb. I probably lost some professionalism marks for ignoring/being brusque to him. Otherwise
straightforward. Some questions on basic invx (routine bloods, FAST, trauma series Xrays, KIV CT if stable)

1) Set IV plug and then order some fluids on the IMR. Dunno how to use the plug, wasted a lot of time.
2)
Insert IV cannula for a patient post-RTA with pelvic fracture, and write in the paper IMR what fluid regime you
would give the patient.

PREPARATION:
FILL UP BLOOD FORMS FIRST!
1. Greet patient.
2. My name is Dr Png. I am the doctor here. I am here to set a cannula and take some bloods for you.
Would it be ok if I proceed?
3. Check name, ID, NHS number, date of birth. Compare with wrist band and consent form

Prepare equipment
4. Hand washing
5. Clean trolley, clean white box, clean sharp box.
6. Paste hazard bag on side of trolley.
7. Prepare equipment: Nonsterile gloves, tourniquet, swab, plug, flush, tegarderm, blood bottles.
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Procedure:
8. Wear apron. Wash hands with alcohol.
9. Put on gloves
10. Apply tourniquet
11. Place sterile paper under the hand. Place the cannula, gauze, tegarderm on the sterile paper.
12. Find vein. Cleanse skin using alcohol swab.
13. There will be a sharp scratch sir. Insert cannula.
14. One flash back is seen and cannula is in, draw blood for blood tube. Connect vacutaner and connect
blood tubes.
15. After everything done, release tourniquet, cap the cannula.
16. Tap down the cannula, flush cannula. If patient tape down with tegarderm.
17. Throw needle immediately into the sharp bin.
18. Thank patient
Post procedure
19. Dispose waste in clinical waste bags, sharps in sharp box.
20. Remove gloves and dispose in waste bag
21. Clean the trolley
22. Wash hands
23. Ensure that the bottles are labelled. Ensure that tegarderm is labelled.
24. Document the procedure in the patient’s notes.

Check name, ID, NHS number, date of birth5. Procedural skills: Plug setting
Stem: RTA with low BP. Set plug and write down your IV drip orders
Questions: Which plug to choose. How to prime IV drip. Explain your fluid orders

CPS – my first station .blood culture taking. 10mins for this station was very tight most people couldn’t reach
the end. Remember ask for consent and wash hands before. Fill up the blood forms first!

HANDWASHING

1. handwashing, gowning, degowning (will check under UV light!!)

2. insert IDC for ARU - quizzed on causes of anuria

INDICATIONS FOR SHORT-TERM CATHETERISATION

1. Relief of acute retention of urine, e.g. benign prostatic hypertrophy, bladder outflow obstruction.
2. Bladder washout, e.g. blood clots causing acute retention of urine.
3. Cystourethrogram.
4. Administration of intra-vesical drugs.
5. As an adjunctive measure pre/post-operatively
a) Pre-operatively:
(i) to drain the bladder so as to improve access to the pelvis in urologic or pelvic surgery.
(ii) to allow accurate measurement of urine output in major surgery.

b) Post-operatively:
(i) to relieve acute urinary retention because post –op pain results in failure of the sphincter to
relax.
6. Urinary output monitoring, e.g. in patient with hypovolaemic shock or the critically ill.

INDICATIONS FOR LONG-TERM INDWELLING CATHETERIZATION

1. Refractory bladder outlet obstruction.
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2. Chronic retention of urine, eg. neurogenic bladder.

3. Incontinence, e.g. in palliative care of terminally ill or patient’s preference.
 
CONTRAINDICATIONS
1. Presence of urethral injury, as manifested by:
a) blood from the meatus,
b) scrotal haematoma,
c) pelvic fracture, or
d) high-riding prostate, elicited from a genital and digital rectal examination. (alternative: suprapubic
drainage)
2. Urinary tract infection, as an indwelling catheter causes difficulty in treatment.

PROCEDURE

PREPARATION:
1. Greet patient.
2. My name is Dr Png. I am the doctor here. I am here to insert a urinary catheter for you. It may be
slightly uncomfortable. Would it be ok if I proceed?
3. Check name, ID, NHS number, date of birth. Compare with wrist band and consent form

Procedure
4. Hand washing with alcohol
5. Place towel and non sterile clean gloves beside patient on bed.
6. Clean trolley, open the catheter set. That is the sterile field.
7. Paste hazard bag on side of trolley.
8. Place drape underneath patient’s perineum.
9. Tear iodine and pour over cotton wools.
10. Tear lub and squeeze out.
11. Check urinary catheter and connect water syringe.
12. Transfer entire sterile field to side of patient
13. Use left hand to hold penis (contaminated hand). Use right hand to sterilize and clean patient.
14. Insert lignocaine gel is available.
15. Dip end of catheter in lub, insert gently.
16. Once urine is seen, use left hand to secure penis and catheter. Use right hand to inject water.
17. Gently pull catheter until inflation balloon is snug against bladder neck.
18. Connect catheter to drainage system.
19. Secure catheter to abdomen or thigh, without tension on tubing.
20. Place drainage bag below level of bladder.
21. Evaluate catheter function and amount, color, odour and quality of urine.
22. Remove gloves. Dispose equipment appropriately. Wash hands.
23. Document size of catheter inserted, amount of water in balloon, patient's response to procedure and
assessment of urine.

Complications
1. Infection, which may lead to stone formation. After 48 hours, most catheters are colonized with bacteria,
leading to possible UTI and complications.
2. Stricture formation due either to faulty technique or an irritant material used in the catheter.
3. Creation of a false passage due to wrong technique of insertion.
4. Occasionally, irritation of the bladder may cause severe bladder spasms.

Alternatives: Suprapubic catheter, Urosheath.

Anuria is defined as <50ml/day of urine and can be divided into:

Pre-renal, renal and post-renal causes.
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Post-renal causes, which by obstruction need to inform bilaterally, can be divided into obstructive and
neurologic causes.

SUTURING
Procedure skills
Give 3 scenarios
Demostrate hand tie with non absorable suture (silk) to tie 2 rubber tubes together like jnj model
Demonstrate hand tie in deep cavity

Wat can u do you help? (double handed hand tie, good retraction)

Demonstrate how you do figure of 8 for hemostasis

Need to demonstrate you can choose suture

What is vicryl (synthetic material, polyglactin whatever)

Non absorbable sutures:

Silk (Natural, braided). Tensile strength lost at 1 year.
Prolene and Nylon (Synthetic, monofilament). Tensile strength 2 years.

Absorbable sutures:
Monocryl and PDS (Synthetic, monofilament). Tensile strength 3 weeks
Vicryl (Synthetic, braided). Tensile strength 4-6 weeks. 56-70 days

How is the suture absorbed?

Enzyme degradation
Hydrolysis

Suturing a wound. They tell you specifically to use non-absorbable and the put a pack of vicryl and a pack of
nylon for you to choose. And then asked you to pick out ur own instruments
Pick the nylon.

6. Suturing skills consist of 3 parts:

- hand tie of vessels
- surgeons knot of deep visceral structures
- undermining of bleeding vessel with figure of '8' suture 
Questions: type of suture: they gave a 6 different sutures without the packaging and asked the candidate to
choose which suture to use for each of the above knots
they also asked re the characteristics of each suture and how you identify them, duration of tensile strength
- hand tie: silk (black , braided, non absorbable)
- surgeons knot of deep visceral: prolene (blue, monofilament, non adsorbable, lots of memory)
- undermining vessels: vicryl (braided, adsorbable, last 4-6 weeks)

Chose the taper point needle. Not the cutting needle which is for skin.

Suture characteristics:
- Sterile
- Hypoalergenic
- Uniform diameter
- Carcinogen free
- High tensile strength
- Pliability for ease of handlin
- Cost effective
- Predictable absorption profile
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CPS – suture tying. Hand tie on hook / ligate bleeding artery / tie two vessels .
Provided w vicryl / prolene / pds. You have to choose your suture and your method of tying. Some questioning
on the duration of suture and the types of sutures used.

OPERATIVE LISTING
Arrange operative schedule
1 mrsa wound for bka, diabetic
2 pacemaker with copd, strangulated Hernia
3 hartmann procedure for diverticulitis

Arrange op sequence
Strangulated hernia first
Diverticulitis second
MRSA last

For normal DM patients for op, normally arrange first on the list.
This reduces period of starvation and risk of hypoglycaemia.

Diet controlled: Minor surgery: No additional precautions.

Major surgery: Monitor blood glucose and consider starting sliding scale

Oral hypoglycaemics: Minor surgery: Morning dose omitted. Restarted once pt is eating
Major surgery: Commenced on insulin sliding scale

Insulin dependant: For all surgeries insulin dose omitted once patient is fasted. Start insulin sliding scale.

Intraoperative period:
Anaesthesia causes hyperglycaemia.
Consider local, regional spinal or epidural anaesthesia.
Monitor blood pressure and blood glucose throughout.

On the morning of the surgery, start sliding scale of insulin.

Discuss what you will ask theatre to prepare

What consideration for each patient
Diathermy- which for each patient, why
Pacemaker use bipolar diarthermy. Does not interfere with pacemaker settings.

Skin prep

1. DM
2. Dehydrated old lady
3. HIV patient

DM goes first
Dehydrated lady second
HIV patient last.

Theatre precautions in HIV patients:

- Routine universal precautions for all patients regardless of HIV or hepatitis
- Wear facemask with visor or protective eyewear
- Wear impermeable gown and water resistant foot wear
- Keep cuts and abrasions covered
- Double glove.
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- Reduce number of people in the theatre to the minimum.

- Warn all theatre staff to this category 3 risk.
- Label all specimens.
- Use disposable items as much as possible. These should be bagged for incineration after.
- Careful disposal of clinical waste, appropriately labelled as hazardous waste
- Limit the use of sharps, use blunt needles.
- Careful decontamination of theatre after surgery.

-Retrovirus group, may lead to acquired immunodeficiency syndrome (AIDS)

- Virus destroys T helper cells resulting in suppression of body’s immune response.
- Needle stick risk: 0.3%

Factors that increase risk of seroconversion following needlestick injuries:

- Exposure to large inoculation of blood
- Deep penetrating injury
- Visible blood on needle
- Procedures that cannulate blood vessels
- Patient with high viral loads and low CD4 counts

What to consider when administering post-exposure prophylaxis

- Immediate action to wash site liberally with soap and water. Free bleeding of puncture wounds
encouraged.
- Report incident to occupational health for further advice.
- Source patient to provide a sample for testing for Hep B and C.
- Assessment has to be made immediately. Consideration given to risk exposure to Hep B and C as well.
- Decision for prophylaxis based on exposure potential, type of body fluid and route and severity of
exposure

Significant risk:
- Percutaneuous injury from needles, instruments
- Exposure of broken skin
- Exposure of mucous membranes

- Post exposure prophylaxis is usually recommended to healthcare workers if they have had a significant
occupational exposure to blood, or high risk body fluid.
- PEP not offered after exposure through any route with low risk materials (urine, vomit, saliva, faeces).
- Uptake of HIV and processing of antigen may take several hours or days, so there is a window for
therapeutic intervention.
- Zidovudine should be given within 1 hour of exposure.

Medication, triple therapy given for 6 months.

Zidovudine
Lamivudine
Nelfinavir

EXCISION OF NAEVUS AND LUMP

[3] Excision of benign naevus. Skin is infiltrated and cleaned already. Consultant ran off to emergency OT once
again. You select instruments (they give 2 of each type – scalpel, scissors, forceps, sutures – so select the right
ones) and do the procedure. Explain to the patient the situation first to ensure consent taken etc. The foam thing
can’t be closed properly so just make a show of it but don’t try so hard the foam keeps cutting through or you
just waste time. Timing can be quite tight here.
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Check patient’s identity

Confirm procdure
Confirm site.
(Check with consent form)

Use the size 10 curved scapel (size 11 is straight, size 15 is small)

Non toothed forceps to loads the blade
Toothed forceps for suturing
Corrugated needle holder for suturing.

After procedure, inform patient about dressing

Inform patient about suture removal.
Inform patient about follow up for histology results.

Excision biopsy of a skin lesion, and T&S. There is a fake skin plastered onto the patient's thigh, then all the
surgical equipment is lay out on the surgical table, you're supposed to pick the correct equipment to use for the
excision and then T&S, including type of blade, forceps, needle holder, type of suture material to use. The
examiner does not talk to you, he's like a fly on the wall, watches your excision/suture technique

Check patient’s identity

Check procedure
Check site

Check drug allergies.

Check comorbides and indication for op.

LA with xylocaine and adrenaline

Give a ring block around the mole

Identify the mole, mark out an elipse around it.

Make an elliptical incision around the move, along the lines of langhans.

Excise the superficial layer with the mole intact

Send for histology

Check for bleeders

Clean and closure with subcuticular sutures with monocryl or interrupted with prolene.

Remember to tell patient about dressing and suture removal in 10 days.

Also to follow up for histology report.

3) Excising a lump. Similar to above, but make sure you do ur own time out. Check patient’s identity,
consent form was there for you to verify with patient. Remember to tell patient about dressing and suture
removal and to come back for histology report. (The patient was nice and asked me everything so that I can
answer them)

Sebaceous cyst removal

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LA with xylocaine and adrenaline

Give a ring block around the lump

Identify the punctum.

Incision along the line of langhans, including the punctum.

Blunt dissection using mosquito.

Pull skin aside using ellis forceps

Use scissors to perform blunt and sharp dissection

Keep capsule intact.

Excise the sebaceous cyst with capsule intact

Send for histology

Check for bleeders

Clean and closure with subcuticular sutures with monocryl

Old man cutting a cord with his knife, sustained laceration of the right thigh.
Placed 3 stitches, asked him for tetanus jab (has not been to a doctor for a long time), was the blade clean?
Counselled him that need to take IM tetanus toxoid, wound management, e.g. can shower with waterproof
dressing but cannot bathe, after 48 hours wound will be water proof, STO 10 days, will give letter to GP

CONSENT TAKING
4. Pre-operative assessment
Stem: Elderly gentleman going for Lap. Cholecystectomy. Determine if he is fit for op.
Findings: Right pace maker. No signs of overanticoagulation or valve replacement. Abdo has a stoma and
midline laparotomy scar. Clinically no abd pain and no complains of RIF pain

Questions:
- Preoperative cardiac assessment, what you looking for in examination, history taking. What investigations.
Preop,op and postop management of pacemaker.
- Should he proceed with op: No, as pt asymptomatic. Difficult abdomen for lap chole in view of previous
surgery, stoma. Laparoscopic requires insufflation and thus raised intraabdomen and subsequently raise
intrathoracic pressure, not suitable in this patient. Thus conservatively managed as pt asymptomatic.