The Agony and The Ecstasy OSCE by Katrina Romualdez

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


Irving, a 26/M, has presented to ED via ambulance who picked him at an outdoor music festival and has brought him to your tertiary ED. He admits to taking "at least" 15 tablets of ecstasy over the course of the afternoon and whilst dancing fell onto his right knee and could no longer weight bear following. SAAS have handed him over as "Probable Knee Dislocation" and there is note of R knee swelling and tenderness. They have given a total of 10 mg Morphine IV about 20 minutes ago. Other pertinent exam findings are dilated pupils (6 mm, equal and reactive) and the following obs...

HR 122
BP 125/75
RR 24
SaO2 98% 4L O2 CIG
T 37.7 C

Knee xrays were taken and the images are attached.
He is currently in a cubicle in a monitored treatment area.

View attached:  Attachment 1  Attachment 2

Instructions for the candidate

Please review the images and on entering the room, perform the following tasks:

1) You have 2 minutes to describe and interpret the images of the R knee to your junior registrar, Kylie.
2) Manage the situation as it unfolds. You will have the junior registrar in the cubicle.

Domains being examined

  • Medical Expertise
  • Prioritisation And Decision Making
  • Teamwork and Collaboration
  • 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

Irving: You are initially compliant if mildly agitated (your best impression of a person who has taken ecstasy). After about 2 minutes, you will become more agitated and attempt to get off the barouche (a bad idea with your broken knee but you "feel" no pain).

When asked or if with access to an iSimulate:
HR now 145
BP 175/85
RR 25
T 38.2 C
SaO2 98% RA

Junior registrar, Kylie: you are incredibly competent butyou have no initiative will be unable to calm the patient down.

For the examiner

Simulation settings:
1st 2 minutes
HR 122
BP 125/75
SaO2 98% on 4 L O2 via CIG
T 37.7 C

After 2 minutes
HR 145
BP 175/85
RR 25
T 38.2 C
SaO2 98% RA

Domains Assessment Objectives

Medical Expertise
- Adequate and systematic description and interpretation of knee xrays
--Presence of prosthesis and healing shaft fracture (not the acute injury)
-- Presence of periprosthetic horizontal distal femur fracture with likely haemarthrosis/knee effusion on lateral film
-- Pertinent negatives

- Recognition of sympathomimetic toxicity requiring treatment (benzodiazepines)
-- recognises and verbalises seizure risk, complications such as hyperthermia, rhabdomyolysis

- Considers/rules out differentials for agitation
-- head injury
-- sepsis
-- heat stroke

- Takes measures to ensure patient and staff safety

Prioritisation And Decision Making
In management of sympathomimetic syndrome
- Staff and patient safety (i.e, security, considers physical restraint depending level of agitation of actor)
- Benzos
- Fluids
- Consideration of (+/- preparation for) intubation if large doses of sedation required, seizures/status epilepticus
- Appropritate disposition depending on response to treatment

Teamwork and Collaboration
- Delegates tasks appropriately
- Recognises need for assistance/other staff (resus call-out, nurses, security)

Leadership and Management
- Calm, confident manner
- Situational awareness

Other Assessment Notes

You must be logged in to add a comment


There are no comments on this OSCE