Thank God you're here OSCE by Michael

 
You have 3 minutes reading time. This OSCE will run for a maximum of 7 minutes.

Scenario:

You are the duty consultant in a tertiary referral ED. You are starting the morning shift at 0800, after a what appears to have been a busy night shift. You are in charge of the 4-bay resuscitation area, and are allocated a senior registrar. You receive a message from the local ambulance service that they are 10 minutes away with a 75yr old woman with chest pain who is haemodynamically unstable.

On the department status board you see that there are 4 patients in the resuscitation room being managed by the night registrar (see attachment).

View attached:  Attachment 1

Instructions for the candidate

You are to:
- Take handover from the night registrar who has been working in the resuscitation area
- Plan the subsequent management of the patients with your team of a senior registrar and nurse
- Plan for the imminent arrival of the new patient

Domains being examined

  • Medical Expertise
  • Prioritisation And Decision Making
  • Communication
  • Leadership and Management
 
The candidate has 3 minutes reading time. This OSCE is expected to run for a maximum of 7 minutes.

For the actor

Day Registrar
You are a competent senior registrar with airway abilities. You are comfortable managing most clinical situations, but prefer to avoid interpersonal conflict. You unquestioningly accept instruction from the candidate.

Nurse
You are a senior nurse, team leader of the nursing team in the resuscitation area today. You have been at work since 07:00 and have a handle on the patients and state of the resus rooms. Your staff are stretched to cover the 4 rooms, with backup nursing staff allocated from the main area. All equipment and supplies are in order. You are concerned that all 4 rooms are occupied, with 1 person intubated and another on NIV. These patients must stay in the resuscitation room until they can be transferred to ICU. You would like to move at least one of the other patients out of the rooms to the main department to have a resus room available.

Night Registrar
You are a competent senior registrar. You are tired and a little frustrated after a busy night with a number of difficulties. You do not want to debrief this morning, but would appreciate the opportunity to do this at a later stage if offered. The patients under your care are:

Resus 1: John JEFFERS
42yo man, driver in MVC vs truck. You have not yet had a chance to fully assess this man (just arrived). ?pulled out in front of truck at moderate speed, truck vs front passenger side. Seatbelt worn, no LOC, extricated by ambulance crew. On primary survey, maintaining own airway, good air entry, SaO2 100% on 15L O2, mild tachycardia (HR 115) systolic BP 130. Alert, GCS 15, complaining of left flank and chest wall pain.

Resus 2: Joseph GORDON
78yo man with PHx COPD, prior MI, HT, T2DM. Presents with infective exacerbation COPD worsening over last 4 days. Arrived in respiratory distress, SaO2 78% on RA with ambulance. Initial ABG showed type 2 respiratory failure. He is on bilevel NIV with pressures 15 inspiratory: 8 expiratory, FiO2 40%, maintaining SaO2 at 95%. He has had regular salbutamoI and ipratropium nebulisers, prednisolone and IV antibiotics. He was seen by the night ICU registrar at 0500 who advised weaning off the NIV because there were no ICU beds. This is one of your frustrations. He is slowly improving and relatively comfortable. His ABGs at arrival and 1 hour ago are:
arrival 1 hour ago
pH 7.21 7.32
pCO2 84 65
pO2 54 87
HCO3 35 31

Resus 3: Beryl WILSON
82yo female PHx prior bowel CA resection, HT, AF. Presented with worsening abdominal pain over 1 day, associated vomiting, reduced bowel motions/flatus. Abdomen generally tender with guarding and peritonism. Erect CXR and subsequent CT abdo showed free gas consistent with perforated viscus. You called for a surgical consult at 06:30 but the registrar was doing a procedure. You called again at 07:15 and the registrar told you it was nearly handover time and to call the day registrar at 08:00. This is also one of your frustrations. Beryl is currently comfortable after IV morphine but her blood pressure has been trending on the low side, currently HR 95, systolic BP 90. She has had 2L crystalloid but has not had antibiotics (you had forgotten to give them). If asked, she is the sickest amongst your patients (although you are unsure about Resus 1).

Resus 4: James SLATER
27yo man with no known past history. Reported to have consumed a decent amount of alcohol as well as GHB. Friends called the ambulance when he became agitated. On arrival to ED he was drowsy, GCS 11 (E3 V3 M5). His BAL was 0.24, bloods unremarkable (no paracetamol level done). Over the next 30 minutes his GCS dropped to 7 (E1 V2 M4) and you elected to intubate him. Uncomplicated RSI, grade I view. Now sedated on propofol at 15mL/hr, ventilated. His ETT and NGT have had position checked on xray. The ICU registrar was informed of his condition at 04:30, but since no beds were available, they have suggested keeping him in ED for extubation when the GHB wears off. This is extremely frustrating for you, as you know ICU have the ability to move non-ventilated patients into the recovery area, but the registrar has refused to do this overnight.

For the examiner

Props:
- patient list for candidate and replicated on whiteboard

Actors:
- night registrar
- day registrar
- resus nurse

This will be a time-pressured station. The night registrar actor should be encouraged to deliver a brief handover and answer any questions, and then depart, leaving some time (ideally ~2 minutes) for a planning discussion amongst the day team.

Domains Assessment Objectives

Medical Expertise
Appropriate management plans for all patients with different system pathologies

Prioritisation And Decision Making
Clear prioritisation and delegation of tasks

Communication
Active listening and questioning of night registrar
Clear delegation and instruction to day staff of status and plans for each patient

Leadership and Management
Management of multiple critically ill patients
Supervision of junior staff
Advocacy and support for night registrar, including ensuring timely departure, offer of debrief and correction of missed medical management
Consideration of state of main department in context of busy resus area

Other Assessment Notes

Sensible and structured approach to handover
Identify sickest patients and immediate needs
Identify outstanding tasks that need completing and appropriately delegate
Identify need to discuss cases directly with ICU and surgical consultants to ensure timely management (not to delegate to registrar)
Identify need to follow up with night registrar to debrief and feedback on management as well as outcomes of discussions with inpatient/ICU teams

Bonus points: explore advanced care directives/limits of care where appropriate.
Controversial: role of asking night staff to stay and assist


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