ACEM example: An early morning fall OSCE added anonymously 

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


The patient is an 80 year old lady who was brought in by ambulance with leg pain. You are in a small district emergency department and it is 08:00 am. You have just arrived to find the night RMO looking after the patient in an acute bed.

View attached:  Attachment 1

Instructions for the candidate

The patient was found lying in the bathroom by the neighbour. She has severe leg pain and is unable to stand.
She is drowsy and confused. It appears that she has had a fall.
An ECG has been taken. You are required to describe the ECG to the junior doctor and then proceed to manage the patient as appropriate. It will be expected that you will manage the patient in the room that she is currently in with the staff that you have there.

Domains being examined

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

For the actor

Nurse. You are an experienced ED nurse with usual procedural skills such as IV cannulation, Urinary catheterisation.
You will efficently perform tasks as directed but should not volunteer tasks. When you are asked to take obs
You should do so as you normally would and report the results back to the doctor.
You have already performed an ECG and when asked for it, give it to the candidate.

It is 0800. You are just completing night shift. The patient came in 30 minutes ago by ambulance. You have commenced initial management, knowing that the candidate would arrive for his usual shift very soon. You are a junior doctor hoping to do ED as a career. You are interested and enthusiastic, but quite junior, PGY3. You will ask the candidate to assist you in the assessment of the elderly drowsy patient who you think may have had a fall and probably has a fractured hip.

You have already put in a cannula and sent off bloods, and have noted that the patient is in AF.

You will assist the doctor in tasks within your capacity as an RMO, as directed. It is expected that the candidate will be teaching you as the scenario unfolds.

It is expected that the candidate will recognise the ECG changes showing hypothermia and explain them to you. It is also expected that the candidate will proceed to actively warm the patient with “bear hugger”, warmed IV fluids etc but that they will not proceed to more invasive interventions until limits of care have been established.

For the examiner

The ECG shows slow AF with Osborne J waves and shivering artefact suggesting hypothermia. When the doctor asks for the patients temperature, you give the temp - 31 degrees C.
The patient is cold, pale, with a slow pulse and low BP. P 45, BP 80/60 mmHg. SpO2 not giving a good trace.
These observations should be given when requested.
The candidate is required to describe the ECG to the junior doctor and then proceed to manage the patient as required.
The candidate should actively warm the patient with bear hugger, warmed IV fluids, and other non-invasive measures.
More aggressive managemant may be possible but may not be appropriate. It is expected that the candidate will attempt to establish limits of care in some way. The patient lives independently but has an Advance Resuscitation PLan which says for usual therapy such as IV fluid, IV antibiotics etc, but not for intubation, ICU.
When the candidate requests the patients chart it arrives after a delay and it has a completed Advance Resuscitation Plan in it.
If the candidate suggest hat the patient should have a CT scan of her head and pelvis hip x rays then they can be provided.
CT head shows no acute injury,
X ray shows # NOF.
The patient has a daughter who lives nearby but she has not answered her phone.

Domains Assessment Objectives

Medical Expertise
Demonstrate knowledge of the recognition and management of hypothermia.
Recognise that aggressive interventions may precipitate VF

Prioritisation And Decision Making
Recognise that the patient is critically ill. Commence immediate re-warming

Communicate the urgency of the situation clearly to the doctor and the nurse.
Teach the RMO abut the ECG

Health Advocacy
Check for advance resuscitation plans etc in order to inform the resuscitation of this elderly patient.
Respect the prior wishes of the patient to have usual treatment but not ICU.

Other Assessment Notes

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