There's some air in there (part I) OSCE by Michael

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

Scenario:

Your registrar approaches you about a 22-year-old male who presented with pleuritic left sided chest pain and SOB. Onset was 15 minutes ago. He has a history of a previous spontaneous pneumothorax, and this feels similar.

His vitals are:
HR 105
BP 110/70
RR 28
SaO2 96 RA

View attached:  Attachment 1

Instructions for the candidate

You are the consultant on. The patient is in a resus room, and you are working with a registrar and a nurse. You are to explain the findings on the x-ray to your registrar and develop a management plan. You are to assist the registrar in managing the case as it unfolds.

Domains being examined

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

For the actor

Patient
You are an otherwise fit and well male. You smoke, but have no other medical conditions nor take any medications. No allergies. You have had one previous spontaneous pneumothorax on the left that was managed conservatively. You feel quite short of breath and anxious.

You are relieved after the chest catheter is inserted. About a minute later you develop severe, sharp, pleuritic pain on the left again with shortness of breath and significant distress. This settles with adequate analgesia.

Registrar
Junior and competent. You've previously seen open thoracostomy and chest drain insertion for this, and have never done a seldinger chest catheter. You are keen to observe this procedure. You are blissfully unaware of the spontaneous pneumothorax management guidelines, but did see a post about sending these patients home with a Heimlich valve.

Nurse
You are a competent ED nurse who seemingly takes joy in making no decisions. You can do anything you are instructed to do quickly and safely.

For the examiner

Requirements: small bore intercostal catheter, actor and/or mannequin

This is a long scenario for 7 minutes.
The elements to explore are:
1. Interpretation of x-ray (1 minute)
2. Management plan (1 minute)
3. Set up and insertion of chest drain (4 minutes)
4. Assessment of deterioration (1 minute)
5. Analgesia options (and we're out of time)

Deterioration is due to pain and distress. SaO2 will remain normal. It is expected the candidate will examine the patient and drain to ensure function.

Domains Assessment Objectives

Medical Expertise
Management of spontaneous pneumothorax
Insertion of chest drain

Prioritisation And Decision Making
Appropriate stepwise approach to management and assessment

Communication
Clear explanations to staff and patient of diagnosis, plan and ongoing care

Health Advocacy
Might as well mention quitting smoking, avoiding SCUBA, and future need for pleurodesis

Scholarship and Teaching
Clear explanation of x-ray and procedure to registrar

Other Assessment Notes

1. Mx spont ptx
- Appropriate choice of approach (small bore chest catheter, UWSD, admission)
- Identify potential for tension pneumothorax and decompress if required

2. Reinflation pain
- Assess patient to exclude other complications
- Adequate analgesic plan (parenteral opioids, intrapleural local anaesthetic)


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