There's some air in there (part II) 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. He was found to have a large left-sided spontaneous pneumothorax and an intercostal drain was inserted. He had some reinflation pain that settled with analgesia.

It is now 2 hours after chest drain insertion, and he is becoming increasingly SOB again. His vitals are:

HR 95
BP 135/90
RR 28
SaO2 94% on 6L O2

A CXR is taken.

View attached:  Attachment 1

Instructions for the candidate

You are to briefly assess the patient and formulate a management plan. You will be assisted by your registrar and an ED nurse.

Domains being examined

  • Medical Expertise
  • Prioritisation And Decision Making
  • Communication
  • Professionalism
 
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 were relieved after the chest catheter is inserted, but had severe, sharp, pleuritic pain on the left again with shortness of breath and significant distress. This had settled with adequate analgesia.

Over the last 30 minutes you have become increasingly short of breath. There is no additional pain. When the diagnosis is explained, you become angry that this is the 2nd adverse event associated with this procedure.

Registrar
Junior and competent. You inserted the chest drain and are a little upset there is another complication. You eventually ask if this is your fault.

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.

If the candidate asks for non-invasive ventilation, question whether this is safe in someone with a pneumothorax.

For the examiner

On auscultation, there are left-sided widespread (mainly basal) coarse crackles. The chest drain is swinging but not bubbling.

Domains Assessment Objectives

Medical Expertise
Assessment of increased SOB in patient with chest drain in situ
Management of unilateral pulmonary oedema

Prioritisation And Decision Making
Clear management plan generation

Communication
Clear explanation to patient and registrar of diagnosis (re-expansion pulmonary oedema)

Professionalism
Management of complaint and registrar feeling guilt

Other Assessment Notes

1. Assessment
- Clear and structured approach to assessing patient with chest drain in situ
- Check tube position, function, auscultate

2. Management
- Supplemental O2
- Analgesia prn
- consider CPAP - if suggested, need to justify use in PTx (chest drain in situ) and outline what needs to be monitored (may develop pneumothorax on other side)
- no role for GTN or frusemide (but not critical error - will lead to some hypotension)
- disposition to high dependency

The management is supportive with increased supplemental oxygen and analgesia. In some cases, NIV, or even intubation and ventilation, has been required. In a refractory case, selective lung ventilation has been described.

3. Complaint management
- Acknowledge patient dissatisfaction
- Outline plan to deal with adverse event
- Counsel registrar


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