Download - SCHHS Emergency Department

SCENARIO 1
Aspiration/#ankle
Domain
Criteria for High Rating
Medical
Expertise
Discusses nature of original injury.
Examiner’s form
Explains need for urgent reduction.
Outlines what has occurred.
Explains consequences of aspiration and appropriate care.
Communication Clear and concise language. Jargon free.
Clearly acknowledges that a complication has occurred.
Reassures mother that Paul will be recover.
Appropriate use of body language.
Allows for questions
Health
Advocacy
Takes responsibility for arranging on going care
Professionalism Shows respect and empathy. Professional appearance and conduct.
Use of appropriate language tailored to Sarah’s understanding.
SCENARIO 1
Candidate’s information
You have just reduced a fracture/dislocation of the ankle of a 15 year old boy
under sedation. An Xray is available for you ti view. Paul injured his ankle at
school in a fall off some rocks. You were unable to contact his parents when he
arrived and due to the nature of the injury, you decided to proceed with the
reduction after discussing it with Paul. Unfortunately, Paul vomited and
aspirated during the procedure. Whilst there is some evidence of aspiration on
a chest Xray, Paul is comfortable and requiring 2L/min of nasal prong oxygen.
The school managed to contact Paul’s mother, Sarah, and she has just arrived.
Paul has given you permission to talk to his mum.
Paul would like you to explain what has happened to his mother.
You have 7 minutes to complete this task
Domains assessed;
Medical expertise
Communication
Professionalism
Health Advocacy
SCENARIO 1
Actor’s notes
You are the mother of a 15 year old boy who sustained a fractured ankle in a
fall at school.
You are concerned, but reasonable and keen to find out how your son is.
The doctor tried to contact you, but was unable to get hold of you. The school
teacher managed to speak to you and told you which hospital your son is at.
You have just arrived and the doctor looking after Paul is here to talk to you.
Paul had a badly fractured and dislocated ankle. The fracture was putting the
blood supply to the foot at risk and was very painful. The required treatment
to restore normal blood flow and help reduce the pain is to realign the
fracture/fix the dislocation under sedation.
Paul suffered a complication, namely he vomited whilst sedated and aspirated
(some of the vomit went into his lungs).
He will need admission to hospital.
Things to ask the doctor
- Have them acknowledge that bit was a complication - ask directly “is
that a complication?” if not volunteered by the doctor
- Ask what treatment is needed for the aspiration if not volunteered by
the doctor
- Ask about the treatment for the ankle if not volunteered
Please allow the candidate time to tell you what they want you to know, but
please ask any questions that you feel are necessary. This should be as realistic
as possible.
Set up/Equipment
1 x actor
Xray of fracture/dislocation of ankle
SCENARIO 2
ICH family discussion
Examiner’s form
Domain
Criteria for High Rating
Medical
Expertise
Interpret CT to high standard and explain scan to daughter
Recognises and explains very poor prognosis.
Discussion about patient’s end of life wishes/advanced care plan - must
focus on the patient’s, not the daughter’s wishes.
Offer’s social work or other support (religious)
Outlines comfort measures and why they are appropriate.
Communication Introduces themselves to the daughter and confirms her name and that
she is Mrs Smith’s daughter.
Appropriate use of body language.
Clear, concise and direct language used when discussing death/dying.
Avoids use of euphemisms.
Offers the daughter the opportunity to ask questions
Health
Advocacy
Daughter will ask about neurosurgery and Intensive care - candidate to
explain that either are unlikely to change the outcome, but should be
happy to arrange consultation if daughter requests it.
Advocate for the patient’s dignity and comfort.
Professionalism Shows respect and empathy. Professional appearance and conduct.
Use of appropriate, tactful language tailored to daughter’s
understanding.
SCENARIO 2
Candidate’s information
An 84 year old female, Mrs Smith, presented to your ED from home after a
collapse. Her GCS is 6. She is currently maintaining her own airway, so you
elect to take her to CT without intubation. A CT brain shows a massive
intracerebral haemorrhage. One of the nurses spoke to her daughter prior to
the CT and she is waiting to discuss the CT result and her mother’s condition
with you.
Please discuss the CT result and what this means for Mrs Smith with her
daughter.
You have 7 minutes for this scenario.
Domains assessed;
Medical expertise
Communication
Professionalism
Health Advocacy
Scenario 2
Actor’s information
You are the daughter of an 84 year old lady, Mavis Smith, who collapsed at
home and was bought to hospital unconscious by ambulance. She has had a CT
scan of her brain and you are meeting with the doctor to discuss how your
mum is and the CT result.
You are quite upset and you suspect the worst. The CT shows extensive
bleeding inside the brain (a type of stroke) and it is unlikely your mother will
survive.
When the prognosis is explained to you, please ask about whether brain
surgery or intensive care could help. If you are satisfied with the doctor’s
explanation of why they would not, you can leave it there. If you are not
happy, ask can you get the opinion of the neurosurgeon or intensive care
specialist - you want to be sure that there really isn’t anything that can be done
to change the outcome.
You have never had a formal discussion about end of life care with your
mother, but you believe that she would want to be kept comfortable if there
was little chance of recovering and continuing to live a reasonably active life.
Please ask any questions you feel are appropriate. This should be as realistic as
possible.
Some suggestions
-
How will you keep Mum comfortable?
How do you know if she is in pain?
Do you think she will die soon?
What will happen now?
CT scan of ICH
SCENARIO 3
Oesophageal intubation
Examiner’s form
Domain
Criteria for High Rating
Medical
Expertise
Obtains relevant handover about the patient - including age, indication for
intubation, drugs used, vital signs
Recognizes oesophageal intubation. Asks about ETCO2/uses to confirm
misplaced ETT. Removes ET tube and oxygenates patient (ventilation can be
assessed by mannequin sensors and must be adequate to pass)
Prepares for repeat attempt at intubation - positioning, in line stabilisation,
equipment, drugs, fall back plan.
Successful intubation. Confirms ET placement with ETCO2 and auscultation
Addresses hypotension post intubation.
Outlines plan for ongoing care - CT, Sedation, ventilator, control of ETCO2
and other strategies to prevent secondary brain injury.
Communication Verbal clarity, conciseness, specificity.
Confident, calm approach.
Graded assertiveness to deal with registrar’s reluctance to step aside
Controls flow communication and verbalizes plan to the team.
Leadership &
Clear leadership ability. Uses leadership skills to deal with registrar
Management
Maintains situational awareness
Prioritizes tasks appropriately
Teamwork &
Collaboration
Utilizes team members effectively
Summarizes and updates team with plan appropriately
Scenario 3
Candidate’s information
This station involves a simulated patient. Please manage the patient exactly
as you would in a real clinical setting.
A registrar in your department is in the process of intubating a patient who has
experienced a polypharmacy overdose. You are unaware of the patient, as
there was no prehospital notification and you are busy with a sick child in the
paediatric area. One of the senior nurses asks for you to come to the
resuscitation bay as the registrar appears to be struggling.
You have 15 minutes for this station. There will be 2 nurses and the registrar
in the room, as well as a simulated patient. Any information about the
patient’s condition that you cannot directly observe from the patient will be
provided by the senior nurse on request. All treatment is to be carried out as
if this is a real patient.
You should assume leadership of the team and coordinate the management
of the patient.
Domains assessed;
Medical expertise
Communication
Leadership and Management
Teamwork and Collaboration
Scenario 3 Actor/Confederate information
The registrar has just intubated a 27 year old man who was found unconscious
in a park. No trauma. It is suspected to be a polypharmacy overdose. The
registrar has used thiopentone 400 mg and rocuronium 100mg. This will result
in post intubation hypotension.
Pre intubation vitals are
P
105
GCS 7
BP
125/70
02 Sats
100% on NRBM
One of the nursing staff is very concerned about the registrar’s intubation
technique and has called out for your assistance.
The oxygen saturations will begin to fall soon after the candidate enters the
room. The registrar and airway nurse are just starting to tie the ETT in position
as the candidate arrives.
The ETT tube is in the oesophagus.
Act as you normally would, but avoid giving the candidate direct prompts
about management unless advised by the scenario leader by radio.
Pointing out vital signs and clinical deterioration is expected and acceptable.
The registrar is certain that the intubation is successful. They are reluctant to
step aside despite falling saturations. “I saw the tube pass through the cords”.
No ETCO2 was used to confirm the initial tube placement.
Set up/equipment
Use Oesophageal intubation scenario
Difficult airway trolley
Choice of induction and paralysis agents
IV access already established
3 actors - 1 airway nurse, one circulation nurse, 1 registrar
SCENARIO 4
Domain
Difficult Airway
Examiner’s form
Criteria for High Rating
Medical
Expertise
Recognises need for intubation. Recognises potential for difficult intubation
and discusses options.
Appropriate preoxygenation and positioning.
Verbalises clear and appropriate plan for failed intubation and performs a
pre intubation check.
Does not persist at attempted intubation for a prolonged period.
Follows plan once intubation fails (mannequin will be set to ensure direct
laryngoscopy is impossible).
Secures airway via iLMA or surgical airway if fails with iLMA
Appropriate post intubation checks and care (ETCO2, sedation, vitals,
auscultation etc)
Communication Clear, concise communication. Closed loop.
Confident, calm approach.
Controls flow communication and keeps unnecessary communication to a
minimum.
Leadership &
Clear leadership ability.
Management
Maintains situational awareness
Prioritizes tasks appropriately
Teamwork &
Collaboration
Utilizes team members effectively
Communicates plan and summarizes management as appropriate
SCENARIO 4
Candidate information
This station involves a simulated patient. Please manage the patient exactly
as you would in a real clinical setting.
You are working at a small regional hospital Emergency Department.
A 48 year old man with influenza pneumonitis has worsening type 1 respiratory
failure. He is morbidly obese and is known to have a grade IV laryngeal view
from a previous anaesthetic.
HR
110
RR
32
BP
150/80 mmHg
O2 Saturation
85 % 15L oxygen via NRBM.
GCS 14 with equal and reactive pupils
On examination he is obviously tiring and becoming more drowsy.
Please mange the patient as you see appropriate.
You will have the assistance of an airway nurse and a junior doctor. Another
nurse who can provide you with clinical information not available from the
patient will also be present and they will identify themselves as the
confederate when you enter the room.
You will have 15 minutes for this station
Domains assessed;
Medical expertise
Communication
Leadership and Management
Teamwork and Collaboration
Scenario 4
Actor/Confederate information
Act as you normally would, but avoid giving the candidate direct prompts
about management unless advised by the scenario leader by radio. Pointing
out vital sign, clinical deterioration etc. is expected and acceptable.
Set up/equipment
Use anticipated difficulty airway scenario
Difficult airway trolley
Choice of induction and paralysis agents
IV access already established
NIV may be requested.
Airway nurse, second doctor and Confederate nurse as a minimum.
SCENARIO 5
Chest Pain Examiner’s form
Domain
Criteria for High Rating
Medical
Expertise
Thorough history of the pain - Nature of the pain, Aggravating/relieving
factors (including exertion, position, movement), radiation etc.
Screening questions for pulmonary cause (pleuritic
pain/cough/fever/SOB)
Risk factors for PE and IHD. Screen for GORD symptoms
Past medical history and medications.
Recognises pericarditis as most likely diagnosis.
Discusses appropriate further investigations on the basis that the clinical
exam is normal.
Communication Verbal clarity, conciseness, specificity. Avoids medical jargon.
Obtain focused history in timely manner without pressuring/rushing the
patient.
Health
Advocacy
Clear explanation that informs patient of likely cause of chest pain and
prognosis and what this means for the patient.
Professionalism Shows respect. Professional appearance, demeanor and conduct.
SCENARIO 5
Candidate’s information
A 45 year old previously healthy man presents to the emergency department
complaining of 2 weeks of chest pain
Please take an appropriate history and review the provided ECG.
After 7 minutes you will be asked to discuss the likely diagnosis and any
alternate diagnoses with the patient.
You will not be required to examine the patient. Vital sign are normal and a
clinical examination was unremarkable.
Domains assessed;
Medical expertise
Communication
Health Advocacy
Professionalism
SCENARIO 5
Actor’s information
You are 45 and called James/Jenny. You started to notice chest pain two weeks
ago, and since then you have been having continuous chest pain with
occasional exacerbations. This is very unusual for you. The pain is a dull
constant ache over the left side of your chest. It does not get worse on
exertion or movement.
It is not worse on deep breathing but you think it might be worse when you lie
down (do not offer this information unless asked).
You are normally fit and well; non-smoker; no blood pressure or cholesterol
problems. No family history of cardiac disease; no previous cardiac problems.
No nausea or vomiting and no shortness of breath. No fever. No reflux
symptoms.
You have taken panadol, but this has only helped slightly.
After the candidate has finished asking you questions and has looked at your
ECG - ask them “what is causing the pain?” “Am I having a heart attack?”
NEED ECG of pericarditis
1 actor
SCENARIO 6
LP
Examiner’s form
Domain
Criteria for High Rating
Medical
Expertise
Checks clear indication for procedure (Post sudden onset of severe
headache. CT at 8 hours post onset is normal)
Establishes that informed consent has occurred.
Ensures landmarks clearly identified, anatomy explained.
Appropriately guides junior doctor through the technique.
Scholarship &
Teaching
Permits the registrar to ask questions
Teaching method that is structured and tailored to registrar’s
understanding
Communication Verbal clarity, conciseness, specificity
Professionalism Shows respect
Professional appearance, demeanor and conduct
SCENARIO 6
Candidate’s instructions
You are asked by a JMO to help them perform an LP on a 42 year old woman
who presented with a severe headache.
The JMO has never performed an LP before, but has assisted at several lumbar
punctures previously. Informed consent has been obtained and the patient is
set up ready for the procedure.
Please guide the JMO through the entire process of performing the LP. The
JMO will be doing the procedure and you will supervise and assist as needed.
You have 7 minutes for this station
Domains assessed;
Medical expertise
Scholarship and teaching
Communication
Professionalism
SCENARIO 6
Actor’s instructions
You are a junior doctor, who has never performed an LP before. You have
assisted before and are very keen to do this LP yourself.
The patient is a 42 year old female who is otherwise well. She presented after
sudden onset of severe headache whilst at the gym. She is alert (GCS15). She
had a CT performed 8 hours after the onset of the headache, which was
normal. It is now 12 hours post onset of the headache.
Informed consent has already been obtained. The patient is ready for the
procedure to begin.
You will perform the procedure as directed by the candidate. Once it is
finished, you will ask the candidate what you should do if the xanthachromia is
positive. If not told what tests to order, please ask the candidate “what tests
should I order”.
Set up/equipment
LP mannequin
LP needles/kit
Syringe
Local anaesthetic
Sterile gloves/drapes/gowns/masks
Actor x 1
SCENARIO 7
Examiner’s form
Domain
Criteria for High Rating
Medical
Expertise
Checks clear indication for procedure and establish that informed consent
has occurred. Discusses risks of the procedure with the JMO.
Inspects CXR and identifies the haemothorax and the correct side of the
patient. Ensures landmarks clearly identified, anatomy explained to JMO.
Discusses analgesia/sedation/local anaesthesia
Gives clear post procedure instructions – repeat CXR, analgesia, record ICC
output, suction.
Ensures that sterile technique is maintained.
Scholarship &
Teaching
Permits registrar to ask questions
Teaching method that is structured and tailored to registrar’s
understanding
Communication Verbal clarity, conciseness, specificity
Professionalism Shows respect
Professional appearance, demeanor and conduct
SCENARIO 7
Candidate’s information
A patient who has sustained a haemothorax in a fall from a ladder requires
insertion of an ICC. You are to supervise and assist a junior ED trainee with the
entire procedure. They will perform the procedure under your direct
supervision.
An Xray of the patient will be available in the room.
The registrar has the patient prepared and ready to start. Informed consent
has been obtained.
The patient, a 54 year old man, is otherwise well and this is an isolated injury.
Pulse 105
BP
115/70
Sat 99% on Hudson mask 8L/min
GCS 15
Last eaten 4 hours ago
You have 7 minutes for this station.
Domains assessed;
Medical expertise
Scholarship and teaching
Communication
Professionalism
SCENARIO 7
Chest tube insertion - Actor’s information
You are a junior registrar working in the ED. You have asked one of the
consultants to assist you in placing an ICC in a patient who has a haemothorax
after a fall from a ladder.
You will perform the procedure under their guidance. Consent has been
obtained and the patient is positioned ready to go. All required equipment is
set up.
Act as you normally would in this situation.
An Xray of the patient is available to view.
Questions to ask:
“Does the patient require IV antibiotics?”
“Does the patient require sedation?”
“Should I connect the chest tube to suction?”
Equipment
Thoracostomy mannequin
LA/needles/syringe
ICC
Sterile drapes
Gloves
1 actor
SCENARIO 8
Candidate’s information
A junior registrar in your department asks for assistance with a 47 year old
man with a history of chronic liver disease secondary to excess alcohol
consumption. He was brought to your emergency department by ambulance
with acute confusion.
The patient’s vital signs are
GCS
12
Pulse
100
BP
120/65
RR
38
TEMP
35.7°C
The registrar has performed a venous blood gas. Please assist them in
interpreting the results.
You will be assessed on your ability to interpret the VBG appropriately, given
the clinical context and assist the registrar in reaching the appropriate
interpretation. You will also be assessed on your ability as an educator, your
professionalism and communication.
You have 7 minutes to complete the task.
Domains assessed;
Medical expertise
Scholarship and teaching
Communication
Professionalism
Scenario 8
VBG result
A 47 year old man with a history of chronic liver disease was brought to your
emergency department by ambulance with acute confusion.
The patient’s vital signs are
GCS
12
Pulse
100
BP
120/65
RR
38
TEMP
35.7°C
VBG
pH
7.21
7.32-7.42
pCO2
14
35-45 mmHg
HCO3
9
22-28 mmol/L
BE
-12.3
-2 to +2
Lactate
11
< 2 mmol/L
Glucose
1.7
5-8 mmol/L
Na
107
134-146 mmol/L
K
4.7
3.4-5 mmol/L
Cl
73
98-106 mmol/L
SCENARIO 8 - Actor information
You are a junior registrar in the department. You have just started seeing a 47
year old man with a history of chronic liver disease due to ETOH. He was
brought to your emergency department by ambulance with acute confusion.
The patient’s vital signs are
GCS
12
Pulse
100
BP
120/65
RR
38
TEMP
35.7°C
You have asked the consultant for assistance interpreting a VBG you have just
performed. Introduce yourself. You will hand the VBG result to the candidate
and ask them to help you interpret it.
Some questions to ask (if not addresses by the candidate)
“What is the anion gap?”
“What is the cause of the high lactate?”
“How do I work out the respiratory compensation?”
“What treatment should I start?”
NEED A CALCULATOR
Laminated VBG result
1 actor
SCENARIO 8
Examiner’s Form
Domain
Criteria for High Rating
Medical
Expertise
Interpret the ABG: Acidaemia. HAGMA. Anion gap of 25. Adequate
respiratory compensation (pCO2 should be 18 - mild resp alkalosis).
Severe hyponatreamia - liver failure, renal failure, SIADH. Very high
lactate - Hypoxia, hepatic failure, sepsis, seizure, poisoning, toxic
alcohols. Hypoglyceamia - Hepatic failure, seizure.
No Delta gap, suggesting a pure HAGMA.
Needs fluid resuscitation (Albumin?), Glucose, Hypertonic saline. Watch
fluid status carefully. Seek and treat possible infection. Consider seizure
as possible cause and monitor carefully. Measure INR and albumin and
renal function - hepatorenal syndrome.
Recognises seriousness of illness.
Scholarship &
Teaching
Permits registrar to ask questions
Teaching method that is structured and tailored to Registrar’s
understanding
Communication Verbal clarity, conciseness, specificity
Professionalism Shows respect
Professional appearance, demeanor and conduct
SCENARIO 9 - Missed Lis Franc injury
Candidate’s Instructions
A patient has represented to your ED today with a painful foot. She was seen in
the ED 7 days ago after injuring her foot in a fall from a horse and discharge
with a diagnosis of a sprained foot and ankle.
She has represented as her foot is not improving. You have a copy of her
original Xrays to view. The films are yet to be reported.
Please interpret the Xrays and discuss the findings with the patient and
address her concerns and outline further management. You are not required
to examine the foot, which is still very swollen and bruised in the midfoot area
and the patient cannot weight bear.
You will be assessed on your communication, professionalism and
management of the patient’s concerns and injury.
You have 7 minutes for this scenario.
Domains assessed;
Medical expertise
Health Advocacy
Communication
Professionalism
SCENARIO 9 - Missed Lis Franc injury - Actor’s instructions
You injured your foot in a fall from a horse 10 days ago. The horse was barely
moving and your left foot became caught in the stirrup when you fell. You
were seen in the ED at the time and told that your Xray was normal and sent
home with crutches and a bandage. You still cannot walk on your foot and are
waiting to see your GP about it.
You received a phone call today from a doctor in the ED, who advised you that
the Xray of your foot was not normal and you need to return to hospital. You
are quite annoyed, as you have been unable to work at your small business
(hairdresser) since the injury and are now concerned you will need even longer
off work. You run the business yourself and hence you have had to close your
business for now.
You can be annoyed/upset, but not rude. You really want to know why this was
not picked up initially and why it has taken 10 days to be called back. Please
ask these questions. You should act just as if this was happening to you.
Also ask:
“What happens now?”
“Do I need an operation?”
“How long will I be off work?”
“Are you going to deal with the Dr who missed this?”
1 actor with bandaged foot
Crutches for effect.
Xray of Lisfranc injury
SCENARIO 9 - Missed Lis Franc injury
Examiner’s form
Domain
Criteria for High Rating
Medical
Expertise
Further investigation and management of LisFranc injury
Correctly interprets the Xray
Communication Allows time for patient to vent frustration. Acknowledges their concerns.
Clear and concise language
Seeks information about social and occupational circumstances
Allows patient to ask questions
Health
Advocacy
Seeks an understanding of the patient’s situation and concerns about
previous presentation. Explores impact on occupation and financial
implications.
Enable patient to make choices, through information, advice and
understanding of his circumstances
Professionalism Shows respect and empathy
Professional appearance and conduct
SCENARIO 10
Consent for LP
Examiner’s form
Domain
Criteria for High Rating
Medical
Expertise
Demonstrates knowledge of role of LP in ruling out subarachnoid
haemorrahge, including the probability of SAH in this patient with a
normal CT.
Demonstrates knowledge of risks/complications of LP
Demonstrates knowledge of consequences of missed SAH
May explore other imaging modalities, but must understand and explain
to the patient that none will demonstrate if a bleed has occurred if the
original CT is normal.
Clear about patient’s decision to have/not have an LP
Communication Clear, concise, jargon free language
Allows patient the opportunity to ask questions
Clearly communicate risk, benefits and what is involved in the procedure
Health
Advocacy
Enable’s patient to make choices, through information, advice and
understanding of risks and benefits of LP - shared decision making
Professionalism Shows respect
Professional appearance and conduct
SCENARIO 10
Candidate’s information
Your task is to discuss the need for a lumbar puncture with the patient, who
presents after onset of a sudden severe headache whilst exercising at the gym.
The headache was occipital, severe and has improved now with analgesia, but
is still present. There is no neurological deficit. No vomiting or fever.
A CT scan of the brain 8 hours after the onset of the headache has been
reported as normal.
The patient is otherwise well.
You have 7 minutes for this task, at which point the patient should have
reached a decision regarding the LP.
Domains assessed;
Medical expertise
Health Advocacy
Communication
Professionalism
SCENARIO 10
Consent for LP
Actor’s information
You experienced the worst headache of your life this morning whilst exercising
at the gym. The headache was at the back of your head, came on suddenly and
was very severe. It has improved now with some analgesia.
You have had a CT scan, which is normal, looking for “bleeding around the
brain”. The candidate will discuss with you the need for a lumbar puncture to
exclude a bleed from a weak blood vessel around your brain - a serious
condition that could result in a life threatening stroke if it was to bleed again.
You are reluctant to have a needle stuck in your back and you should decide
whether to have the LP or not based on your discussion with the candidate.
1 Actor
SCENARIO 11
Paediatric Seizure/Meningitis
Domain
Criteria for High Rating
Medical
Expertise
Recognises seriously ill child.
Examiner’s form
Establishes IO access. Gives drugs to terminate the seizure.
Begins resuscitation and administers appropriate antibiotics.
Addresses enquiry about FEAST trial and fluid resuscitation appropriately
Takes appropriate investigations, including blood culture.
Focused assessment for source of sepsis, strongly considers meningitis
Measures and corrects low BSL
Appropriate plan for ongoing management.
Communication Clear, concise, closed loop communication.
Controls flow of communication and verbalizes plan to the team.
Appropriate handover to PICU consultant
Leadership &
Clear leadership ability. Delegates roles to team members.
Management
Maintains situational awareness.
Prioritizes tasks appropriately.
Confident, calm approach.
Teamwork &
Collaboration
Utilizes team members effectively
Summarizes and updates team with the management plan appropriately
SCENARIO 11
Paediatric sepsis Actor/Confederates notes
The patient is a 14 month old girl called Mia, who has presented with a fever,
reduced oral intake and drowsiness. She has a seizure as the resident starts to
assess them and they call the consultant for assistance. There is no IV access
and it cannot be easily obtained.
She has septic shock, no clear source of infection clinically, but meningitis is
likely. Her legs are mottled and she looks unwell.
Her vital signs are
P
195
Sats 95% RA
BP
60/40
RR
Temp
39.4°C
50
She requires IV access, resuscitation, IV antibiotics and a PICU admission.
Act as you normally would, but avoid giving the candidate direct prompts
about management.
Pointing out vital signs and clinical deterioration is expected and acceptable.
A venous blood gas is available to review. Glucose is 2.4. Only reveal this is the
candidate asks for it to be measured.
The resident will ask a number of questions.
When fluid resuscitation begins, please ask the candidate “what do you think
about the FEAST Trial (showed an increased mortality in paediatric sepsis with
higher volumes of resuscitation) and should this alter our fluid resuscitation?”
“When should we think about inotropes?”
“What do you think about this VBG?” (if one is taken)
2 x Actors. Use modified meningitis scenario and VBG.
SCENARIO 11
Candidate’s Information
This station involves a simulated patient. Please manage the patient exactly
as you would in a real clinical setting
You will be asked to assist with the management of a 14 month old girl called
Mia, who has presented with a fever, reduced oral intake and drowsiness. She
has a seizure as the resident starts to assess them and they call you for
assistance.
You have 15 minutes for this station. There will be 2 nurses and the registrar
in the room, as well as a simulated patient. Any information about the
patient’s condition that you cannot directly observe from the patient will be
provided by the senior nurse on request. All treatment is to be carried out as
if this is a real patient.
Domains assessed;
Medical expertise
Communication
Leadership and Management
Teamwork and Collaboration
SCENARIO 12
REGISTRAR COMPLAINT
Examiner’s form
Domain
Criteria for High Rating
Communication
Clear and concise. Does not shy away from the issue.
Genuinely curious about what happened and why.
Leadership &
Collaborative, non-belligerent approach
Management
Discusses specific issues of the complaint
Listen’s to the trainee’s side of the story
Explores any extenuating circumstances for behaviour
Reaches agreement with trainee on expected level of behaviour
Seeks consent from trainee to feedback to staff member concerned
Professionalism
Consultant level approach. Takes matter very seriously.
Professional and respectful, but firm in recommendations and advice
to the trainee
SCENARIO 12
REGISTRAR COMPLAINT
Actor’s form
You are an ED trainee. One of the pharmacists has made a complaint that you
were very rude to her over the phone. You had written a prescription for
antibiotics for a patient with a UTI, but the pharmacist had a question about
the dose and the indication for using ciprofloxacin for a UTI in a young woman
with no allergies.
You became quite angry with the pharmacist and told them in no uncertain
terms that it was none of their business why you were prescribing ciprofloxacin
and the dose was fine (500mg tds). The pharmacist politely tried to suggest
500mg BD, but you shouted and swore at her to “just give the patient the cipro
like I asked and stop #@&%%* bothering me”. The pharmacist hung up.
You have not been enjoying work recently, after your were involved in
disagreement with an inpatient consultant who did not want to admit a patient
who you thought needed admission with chest pain. The patient went home
on their advice but represented a week later with an AMI. You are bit sorry
about what you said to the pharmacist, but are reluctant to admit it, as feel
that you are the only person working hard here and that if everyone else in the
hospital would just pull their weight life would be much better.
The candidate will be acting as your consultant and has been asked to discuss
the issue with you and make a recommendation to the director.
Please act as if you don’t really care about this incident and you expect the
consultant to just brush off the complaint. However, if they ask you about any
issues you are dealing with, please bring up the recent issue with the inpatient
consultant and your feelings about lack of enthusiasm for work, compounded
by your (unfounded) views on the poor work ethic of those around you.
SCENARIO 12
REGISTRAR COMPLAINT
Candidate’s Information
At this station you will be asked to discuss with a trainee a recent complaint
made against them by one of the hospital pharmacists.
The complaint reads
“The doctor was exceptionally rude to me on the phone. I called to check the
prescribed dose of ciprofloxacin and why it was being prescribed to a young
woman with a UTI, as I am required to do by the hospital’s protocol on
antibiotic prescribing. The dose was prescribed was 500mg tds rather than the
usual BD.
When I asked about this with the doctor, they swore at me, told me it was
none of my business why they were prescribing ciprofloxacin and said ‘just give
the patient the cipro like I asked and stop #@&%%* bothering me’.
I think that this behaviour is clearly against the hospital’s code of conduct
policy and I would like a formal apology and the doctor concerned dealt with.”
Please discuss the compliant with the trainee and make recommendations to
them based on your discussion.
You have 7 minutes for this station.
SCENARIO 14
Toxicology/phone advice
Examiner’s Form
Domain
Criteria for High Rating
Medical
Expertise
Recognizes’ s seriousness of patient’s overdose
Appropriate assessment of clinical picture (risk assessment)
Appropriate recommendation for treatment
- Calcium
- Adrenaline
- Fluids
- High dose insulin and dextrose
- Decontamination
Advice regarding patient transfer - intubation
Communication Clear, concise instructions and recommendations
Clear and concise language
Checks that instructions are understood
Health
Advocacy
Ensures that plans are being put in place to have the patient retrieved
Professionalism Shows respect and is collegial with rural doctor
Professional conduct and supportive of rural doctor
SCENARIO 14
Toxicology/phone advice
Actor’s Information
In this station, the examiner will be the rural doctor making the call for advice.
You are an experienced rural GP who is covering the small local emergency
department, when a 5 year old girl presents after a large calcium blocker
overdose. She was being cared for by her grandmother, who found her with an
empty packet of Verapamil 360mg SR tablets about 2 hours ago.
The child is a currently alert.
Vitals signs
P
50
BP
70/45
Sat
98% RA
Temp
36.4°C
RR
36
You call the nearest Emergency Department to ask for advice on management
of the girl from the Emergency Physician. You have IV access and have given
10mls/kg of N/saline as a bolus. The girl weighs 20 kg. Your hospital is 2 hours
flying time by helicopter from the ED you are calling.
Things to ask the candidate;
“Should I give charcoal?”
Clarify the dose of any medication given.
If they mention high dose insulin/dextrose - ask about why and can you give it
through a peripheral cannula?
Phone x 2, Blood gas results for GP (if asked)
SCENARIO 14
Candidate’s Information
You will receive a phone call from a GP who works at a small rural hospital
which is about a 4 hour drive away.
The GP is managing a 5 year old girl who has accidentally taken a large number
of her Grandmother’s calcium channel blocker medication.
Please provide advice to the GP over the phone. The phone will ring once you
enter the room. The GP role is being played by the examiner.
You have 7 minutes for the station.
Domains assessed;
Medical expertise
Communication
Professionalism
Health Advocacy
SCENARIO 15
Suicidal Ideation
Examiner’s form
Domain
Criteria for High Rating
Medical
Expertise
Assess suicide risk in a thorough and formalized way.
Assess options for safe discharge and follow up.
Communication Clear and concise communication
Direct questions about relevant suicide risk factors
Health
Genuinely concerned about patient’s wellbeing and risk of self-harm.
Advocacy
Professionalism Shows respect and empathy
Professional conduct and non-judgmental approach
The actor’s suicide risk is actually low (score 4 below), but a thorough formal
assessment should be made elucidating the following or similar factors;










S: Male sex → 1
A: Age 15-25 or 59+ years → 1
D: Depression or hopelessness → 2
P: Previous suicidal attempts or psychiatric care → 1
E: Excessive ethanol or drug use → 1
R: Rational thinking loss (psychotic or organic illness) → 2
S: Single, widowed or divorced → 1
O: Organized or serious attempt → 2
N: No social support → 1
S: Stated future intent (determined to repeat or ambivalent) → 2
This score is then mapped onto a risk assessment scale as follows:



0–5: May be safe to discharge (depending upon circumstances)
6-8: Probably requires psychiatric consultation
>8: Probably requires hospital admission
- May be suitable for discharge and follow up with GP/community
mental health team, but lack of a responsible person to take the
patient home, psychiatric consultation likely to be required.]
SCENARIO 15
Suicidal Ideation
Actor’s instructions
In this scenario, you will be playing the role of a young woman who has
presented to hospital after taking 10 paracetamol tablets following a fight with
her boyfriend. The candidate will be asked to assess your risk of suicide. If you
DO NOT think that you can play this role for any reason or it becomes difficult
for you at any stage, please advise the examiner.
Your actual risk of suicide is now low.
You had your first major fight with your boyfriend of 4 months. You were angry
and upset at the time, and in that distressed state, you took 10 paracetamol
tablets telling him that you wanted to kill yourself. He called the ambulance.
Soon after taking the tablets you regretted it and you don’t really want to die
now, but at the time you thought that you did. You have no plan/date for any
future suicide attempts and do not feel suicidal now.
You are otherwise well.
When you were 24 years of age you took an overdose of nurofen tablets, with
no ill effects, but were admitted overnight to hospital. You were treated for
depression with medication (Effexor) for 2 years after that episode, but have
been feeling well since and have been free of medication and counselling for
nearly 5 years. No other psychiatric history or medical history. No family
history of mental illness.
You live in a share house with 2 friends. You are studying Architecture at
University and will finish at the end of the year.
You do not feel helpless or hopeless, but have been struggling with money and
your university studies as you try to balance studying and working.
You do not use any illicit drugs, but drink 4-5 glasses of wine each night.
Your family live in Melbourne and you do not have much contact with them.
No local family. If you were discharged you would head home to your share
house. You have a GP that you could see in the next few days. You want to go
home.
SCENARIO 15
Candidate’s Instructions
You will be asked to assess a young woman for ongoing risk for suicide. She
present’s after taking 10 x 500mg paracetamol tablets after a disagreement
with her partner.
Please focus your assessment on her suicide risk. You have 7 minutes for this
station. At the end of this scenario, please discuss with the patient what you
think their risk of suicide is and what will happen next.
Domains assessed;
Medical expertise
Communication
Professionalism
Health Advocacy
SCENARIO 16
CXR/REQUEST FOR ADMISSION
Domain
Criteria for High Rating
Medical
Expertise
Recognizes’ s need for admission
Examiner’s form
Interpret CXR findings correctly in light of clinical picture
Communication Clear and concise language
Clearly and effectively communicated need for admission
Graded assertiveness to deal with Respiratory consultant’s reluctance
Health
Advocacy
Advocate on behalf of patient for appropriate care from inpatient team
Professionalism Shows respect and is collegial with Respiratory Physician
Professional conduct
You will play the role of the respiratory consultant on the phone. You are to be
obstructive and not keen at all to admit the patient. The resident who spoke to
you earlier could not clearly explain the Xray findings. Please be sure to clarify
what the Xray shows. Eventually the candidate should be able to convince you
that the patient does require admission. Please keep an eye on the time. The
phone call should go for no more than 7 minutes.
SCENARIO 16
CXR/REQUEST FOR ADMISSION
Candidate’s Information
A resident in your department has attempted to refer a patient to the
respiratory team for admission, but the respiratory consultant Dr Blogs does
not think the patient requires admission. The resident is very concerned about
discharging the patient as they feel that they are unwell and their social
situation will impact on their treatment.
The patient, John Smith, is a 32 year old man who presents with a productive
cough, lethargy and fever for 5 days. He admits to being an IV drug user and is
currently of no fixed abode and has no money. He has previously had bacterial
endocarditis. He has no other significant past medical history.
On exam, He looks unwell. He is mildly dehydrated.
P
110
Sat
100% 2LNPO2
TEMP
38.7°C
BP
95/65
His left lung has some very coarse creps in the mid zone.
WCC 19. Lactate of 1.9. Other bloods are normal.
Her Xray is available for you to review.
Please review his Xray and call the Respiratory team to facilitate his admission.
You have 7 minutes to perform this task.
Domains assessed;
Medical expertise
Communication
Professionalism
Health Advocacy