Examiner: 

• "You've just been alerted to an incoming trauma. A 30-year-old male is being brought in by EMS to your trauma bay with a gunshot wound to the right abdomen and flank. EMS is stating his initial blood pressure is 90/60 mmHg and his heart rate is 130 bpm. They are 5 minutes out."

Examinee: 

• "My initial steps would involve assembling the trauma team and ensuring that the trauma bay is prepared with all necessary equipment, including airway management tools, intravenous and intraosseous access supplies, and monitoring devices. I would also ensure that blood products are available and ready for transfusion and that the operating room is alerted. I would ensure my team has full PPE on and that roles and responsibilities are delegated. Upon the patient's arrival, I would follow the principles of the ATLS, beginning with a primary survey to assess airway, breathing, circulation, disability, and exposure."

Examiner:

• "The patient arrives in the trauma bay. He is conscious and talking but in distress. He has bilateral breath sounds. His blood pressure is 85/55 mmHg, heart rate is 135 bpm, and respiratory rate is 28 breaths per minute. His SpO2 is 90%. There is a penetrating wound in the right upper quadrant of the abdomen and another wound in the right flank. What is your next step?" 

Examinee:

• "He appears to be protecting his airway but is borderline with his saturations. I would apply a nasal cannula and start at 2L of supplemental oxygen. As he is an unstable penetrating trauma patient, he needs blood product resuscitation and an operation. I would ensure 2 large bore IVs are placed, activate massive transfusion protocol and administer the blood in a balanced 1:1:1 fashion with 1 gram of TXA and Calcium supplementation and I would send a TEG. I would then determine which cavity is the cause of his instability by getting a chest x-ray. I would also use the US to perform a FAST exam to look for pericardial and intraperitoneal fluid. If he did not respond to initial blood resuscitation, I would proceed emergently to the operating room."

Examiner:

• "The chest x-ray is clear, but the FAST exam shows free fluid in the right upper quadrant. The patient's blood pressure drops further to 80/50 mmHg despite ongoing resuscitation."

Examinee: 

• "Given the patient's worsening hemodynamic instability and the presence of free fluid in the right upper quadrant on the FAST exam, I would prepare the patient for an immediate exploratory laparotomy. I would continue blood product resuscitation en route to the operating room and ensure that the surgical team and necessary equipment are ready for rapid intervention. I would ensure the room is as warm as possible and coordinate with anesthesia to perform a midline laparotomy right after induction due to his high risk for cardiovascular collapse from intubation. My first goal would be to pack the abdomen for hemorrhage control and gain supraceliac aortic control to allow anesthesia to catch up in their resuscitation."

Examiner: 

• "Upon entering the abdomen, you find active bleeding from the right lobe of the liver, an expanding right zone 2 retroperitoneal hematoma with bleeding from the superior pole of the right kidney."

Examinee:

• "I would start by packing the right upper quadrant with laparotomy pads with care to re-establish normal hepatic anatomy and pack over the zone 2 hematoma. If this controlled the bleeding, I would perform a systematic exploration of the abdomen to assess for other injuries." 

Examiner: 

• "Packing seems to control the bleeding temporarily in the retroperitoneum, but not on the right lobe of the liver."

Examinee:

• "Since packing did not control the bleeding from the right lobe of the liver, I would remove the laparotomy pads to directly visualize the bleeding site. I would use topical hemostatic agents, such as fibrin sealant or oxidized regenerated cellulose, applied directly to the liver surface and re-pack. If needed, I would place hemostatic sutures of 0 Chromic or Vicryl to secure the agents in place. If bleeding persists, I would use a Pringle maneuver to occlude the hepatic inflow temporarily while addressing the bleeding." 

Examiner: 

• "After a few minutes, the hemostatic agents and a Pringle maneuver stop the bleeding from the liver laceration. Your systematic exploration demonstrates no other injuries. Anesthesia reports your transfusion requirements are significantly improving, and his new blood pressure is 110/80 and his heart rate is 105."

Examinee: 

• "With the bleeding controlled and no other injuries identified, I would carefully remove the Pringle maneuver to restore hepatic blood flow while observing for any recurrent bleeding. I would ensure all hemostatic agents are securely in place and that there is adequate hemostasis. If that is hemostatic, I would mobilize the right colon to better expose the kidney injury and assess the bleeding by carefully removing the packing."

Examiner: 

• "Upon removing the packing, you find persistent bleeding from the superior pole of the right kidney."

Examinee:

• "To address the persistent bleeding from the superior pole of the right kidney, I would first apply direct pressure to control the bleeding temporarily. I would then use topical hemostatic agents on the bleeding site. If the bleeding persists, I would carefully place pledgeted sutures to control the hemorrhage over hemostatic agents or an omental plug." 

Examiner: 

• "Pledgeted sutures over absorbable hemostatic agents controls the bleeding, but you notice leaking fluid from the hilum near the repair."

Examinee: 

• "I would interrogate the collecting system to assess for a urine leak. I would clamp the proximal ureter with a bulldog clamp and inject Methylene blue up the ureter with a 22 gauge needle. If I saw a large leak, I would repair it with 4-0 absorbable suture to prevent a chronic stone nidus."

Examiner: 

• "You repair a whole in the collecting system. The patient is hemodynamically stable and normal now with no ongoing bleeding. They are warm and anesthesia reports no significant acidosis on the recent blood gas."

Examinee:

• "I would place a drain near the renal and liver repairs to catch and urine or bile leaks. I would inspect the abdomen again to ensure no missed injuries. If none, I would close the abdomen and admit the patient to the ICU for further resuscitation."

Examiner:

• "Mr. Smith, a 55-year-old male, underwent an exploratory laparotomy for a traumatic liver laceration 5 days ago. He was making good progress but reports feeling a sudden "pop" at his incision site while working with physical therapy on postoperative day 5. He then noticed some leakage of salmon-colored fluid from the wound and a new bulge at the site. On examination, the wound is bulging, and there is serosanguinous discharge through several staples."

 Examinee:

• "My initial concern is for fascial dehiscence, indicated by the sudden 'pop' sensation and the leakage of salmon-colored fluid. I would begin with a thorough physical examination of the wound to assess the extent of dehiscence and check for signs of infection or evisceration. I would also evaluate Mr. Smith's vital signs to ensure hemodynamic stability and I would send labs to check for infection, bleeding, or electrolyte disturbances to include a CBC, a BMP, and a lactic acid." 

Examiner:

• "His vital signs are stable and he is afebrile. The wound shows separation of the fascial layer with visible bowel in the subcutaneous space. There is no surrounding cellulitis. His CBC demonstrates a leukocytosis to 14 and a lactic acid of 2.5, but they are otherwise stable and normal." 

Examinee:

• "Given the visible bowel in the subcutaneous space, this represents a significant fascial dehiscence. I would start by ensuring the bowel is protected and kept moist with saline-soaked gauze. I would maintain the patient NPO and continue intravenous fluids. Prophylactic broad-spectrum antibiotics would be administered to prevent infection. Given the severity of the dehiscence, I would prepare the patient for an urgent return to the operating room for surgical repair of the fascial defect. As infection can play a large role in dehiscence at this stage of his recovery, and he has a leukocytosis, I would get a pre-operative CT scan to assess for any abscesses that I would need to ensure drainage of intraoperatively." 

Examiner:

• "The CT scan shows a rim-enhancing fluid collection in the right upper quadrant near the previous liver injury. It appears to be tracking toward the midline incision."

Examinee:

• "I would start the patient on antibiotics and ensure the patient is resuscitated. I would counsel the patient on benefits and risks of proceeding with operative exploration of his wound with drainage of the fluid collection. If the bowel wasn't eviscerated and the abdomen frozen, I would perform a skin closure over a drain or with a wound vac to convert the wound into a controlled hernia with plans for future repair. If the bowel is eviscerated or the abdomen is mobile, I would perform a closure over an absorbable underlay mesh."

Examiner: 

• "The patient consents to proceed with surgery. What is your approach given the bowel is able to be safely mobilized?"

Examinee:

• "I would open the previous laparotomy incision to expose the dehisced fascia and any herniated bowel. I would carefully open the previous repair, separate the viscera from the anterior abdominal wall, and identify, sample, and wash out the right upper quadrant fluid collection and place a drain into the area through a separate stab incision. Any necrotic or infected midline tissue would be debrided back to healthy bleeding tissue. I would raise subcutaneous flaps to allow for suturing a reinforcing absorbable mesh. I would then suture a coated absorbable mesh, such as Phasix ST, in an underlay fashion with care to avoid the underlying viscera. If airway pressures allowed, I would close the fascia over the mesh using interrupted PDS sutures. If a tension-free closure is not possible, I would leave the mesh as a bridging mesh. Hemostasis would be carefully checked, and the wound would be irrigated again before final closure of the skin."

Examiner: 

• "What would you do if the bowel was not eviscerated but the abdomen was frozen?"

Examinee: 

• "I would convert this into a controlled hernia. I would attempt to close the skin over a drain for fluid management to get soft tissue coverage for the bowel. If the skin was unable to be closed, I would perform a wound vac assisted closure with a white sponge on the bowel and a black sponge in the subcutaneous tissues to encourage granulation tissue. I would then consult interventional radiology post operatively for a drain into the right upper quadrant fluid collection."