Trial OSCE exam: 'Exam' by tom glover

You are taking part in a trial exam created by tom glover. There are 9 OSCEs in this exam (90 minutes).
 

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

Scenario:

You are on duty in your regional emergency department. A 67 year old man is brought in by ambulance with breathlessness.

Instructions for the candidate

You are to receive the handover from the paramedic and manage the scenario as it unfolds. You will have one nurse with you. The nurse is an experienced ED nurse.

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

Mannequin with COPD, minimal resp effort.

Nurse. You are a competent ED nurse. Your role is to assist the candidate to set up IV infusions and BIPAP for this patient with critical COPD and acute respiratory depression.

When bloods are taken you send the bloods off and ask other ED doctor to do an immediate VBG, which is done quite quickly. Once the bloods are sent, you can commence IV therapy and after about two minutes the VBG result is available. You can then give it to the candidate.

The candidate should note the high CO2, high O2 and high HCO3 suggesting chronic CO2 retention and acute resp depression secondary to the high O2.

You should set up BIPAP just as would at work. When you are asked to set up IV infusions you should check the dose/rate desired if not given. You will most likely need to set up Magnesium, salbutamol, possibly adrenaline and possibly aminophylline infusions.

Paramedic (examiner two)
You picked up the patient at home. His wife called the ambulance. She is on her way in but waiting for her son to pick her up.
You notes SpO2 75% at home, so started immediate continuous salbutamol nebulisers on high flow O2.
The patient was initially alert and co-operative but has become increasingly drowsy during the 15 minutes that it took to load the patient and bring home to hospital.

His wife stated that he was a heavy smoker until recently when he started home O2. He is on regular low dose prednisolone and regular venlolin nebs but no other medication. On a good day he can get out of the house to walk around the (small) garden, but cannot walk down the street or to the shops as he gets too breathless with minimal exertion. He has improved considerably since starting home O2, but has had a cold for the last couple of days with increasing cough and breathlessnes. He has been coughing up a lot of thick green/yellow sputum for the last 24 hours and has not slept well.

For the examiner

The candidate should assess the patient as having life threatening COPD. The patient is on home oxygen (given on handover) and was initially breathless and hyposic. SpO2 75% at hime. Treated with continuous ventolin nebulisers and with high flow oxygen by ambulance crew. Now patient is drowsy, SpO2 100%.

The candidate should commence immediate assessment and treatment.
Assessment, Opens eyes to voice, mumbles incoherently, localises pain, SpO2 100%, P 120, BP 120/70
Minimal respiratory effort, very quiet chest on auscultation.
The candidate should recognise life-thretening COPD in a patient alreadty on home O2.
They should immediately escalate treatment. IV steroids, IV either ventolin or adrenaline IV magnesium infusion, may choose IV aminopphylline infusion if patient not on long term theophylline (they are not, according to ambulance officers).

The candidate should urgently establish IV access and take blood for FBC, U&Es Glc and most importantly VBG.
pH 6.9
PvO2 120 mmHg
pVCO2 140 mmHg
HCO3 45 mmol
BE 11
Lactate 5 mmol
Na 135
K 3.5
HCO3 45
Cl 80.
Interpretation: Critical acidaemia, Severe respiratory acidosis, with metabolic compensation, therefore CHRONIC CO2 retention. Therefore hypoxic drive. Now SvO2 100%, hypoxic drive lost, acute respiratory depression. High lactate in keeping with initial hypoxia SpO2 at home 75%. Thus additional metabolic acidosis.

Interpretation: This patient is a chronic CO2 retaining patient with long term type 2 resp failure, who now has acute resp depression secondary to uncontrolled Oxygen therapy.

Treatment. Check for advanced health directive etc. Very important in this situation
Also commence immediate NIV BIPAP, to try to assist patient to blow off CO2.
Coninue with intra-venous therapies as above.
NOT a candidate for intubation. Decision easier of an advanced health directive exists.
Urgent discussion with wife/family if they are available regarding likely outcome (death) and futility of more invasive interventions such as intubation.

Domains Assessment Objectives

Medical Expertise
The candidate should recognise that immediate escalation of treatment including IV therapy is urgently needed (ventolin, iprtropium, magnesium, ventolin infusion, possibly adrenaline infusion, possibly aminophylline infusion). Also should recognise the need for immediate BIPAP.

Prioritisation And Decision Making
The candidate should recognise the critical nature of the presentation, but should also recognise quite quickly that aggressive interventions such as intubation and ventilation are probably not helpful and indeed may be harmful.

Communication
Should communicate clearly and appropriately with paramedic and nurse.

Health Advocacy
Candidate should recognise that the patient may have an advanced health directive and should seek that and follow it. They should also state that more invasive therapy such as intubation/ventilation is unlikely to be beneficial and is probably harmful.

Other Assessment Notes