A needle in a haystack OSCE by Michael

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

Scenario:

A medical student currently working in your department comes to you following a needlestick injury while taking blood from a HIV positive patient.

Instructions for the candidate

You are the consultant responsible for medical student supervision. You are to counsel the student about the exposure and formulate a management plan.

Domains being examined

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

For the actor

You are a final year medical student currently rotating in the ED. You have been in the department for 3 weeks. You are enjoying your term immensely.

You had performed venepuncture on a HIV positive man and as you removed the needle he moved, causing the needle tip to pierce the side of your left index finger. You were wearing gloves. The needle was attached to a vacutainer system that you had just completed collecting blood through. If asked, the man is quite apologetic and willing to have his blood tested further if required.

You immediately disposed of the sharp, removed your gloves and washed your hands with soap and water (only provide this if asked what you did).

You immediately sought out the candidate to discuss the events. You are very concerned about your risk of becoming infected with HIV, and feel quite anxious about it and the impact it could have on your life, relationship and career. You are unsure of the man's other infective status (eg hepatitis B & C).

You have a long-term partner whom you live with. Your parents and family live interstate. You have a few close friends nearby. you have no PHx, medications or allergies.

You want to know:
- what are the chances of you becoming infected with HIV, Hep B or Hep C? You want clear figures, not just "low".
- what factors impact the transmission risk?
- what can you do to reduce this risk (first aid, prophylaxis)? How effective are these measures?
- what are the side effects of prophylaxis? Is there anything I can't do while taking them? How do you choose? How long do you need to take them?
- what tests do you need done? Do we need to perform further tests on the source?
- what do you tell your partner?
- how long will it be before you know you are clear (and what is the process)?

Bonus:
- would HIV affect your career as a doctor? You were hoping to do emergency medicine.

For the examiner

None.

Domains Assessment Objectives

Medical Expertise
Knowledge of risk, management and prognosis of needlestick injuries

Health Advocacy
Appropriate risk management, prophylaxis and follow-up

Professionalism
Caring and supportive approach

Other Assessment Notes

- first aid
- investigations
-- exposed person (immunity for hep B, LFTs pre-PEP)
-- source (eg hep B & C, viral load, etc)
- risks of exposure
-- source factors - viral load, compliance with meds
-- transmission factors - amount of blood, etc
-- generic risks (blood in hollow needle, viral load detectable)
--- Hep B 1:3
--- Hep C 1:30
--- HIV 1:300
-- risk of HIV transmission when viral load undetectable likely to approach 0
- PEP
-- indications / contraindications
-- efficacy (~4x reduction in transmission incidence)
-- complications
-- agent choice (guided by ID - local resistance, specific strain of source, treatment regimen of source affects resistance)
- psychosocial
-- partner, career
- prevent re-transmission (barrier protection for intercourse)
- f/up
-- ID, welfare

Bonus
- ensure PPE / OH&S safety
- university requirements


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