Trial OSCE exam: 'last week aahhh (deb and jen)' by Deborah Maher

You are taking part in a trial exam created by Deborah Maher. There are 18 OSCEs in this exam (180 minutes).
 

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

Scenario:

A HMO at a small rural centre calls for help managing a patient with epistaxis.

Instructions for the candidate

You are an emergency consultant at a large Regional Emergency Department. You are about to receive a phone call from a HMO who is working in a small rural hospital 100km away. The HMO is experiencing difficulty managing a patient with epistaxis.

Your roles are to
• Take a brief directed history from the HMO
• Establish a management plan for the patient including disposition

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

You are a HMO 2 working at a small regional hospital.

Your background experience
• You are competent at history taking and examination
• Your experience is limited to simple management of epistaxis including external compression and insertion of nasal tampons. You have never posteriorly packed a nose although are willing to with guidance

Hospital Resources
• You are the only doctor in the hospital. You have experienced nursing staff
• You are able to call in one other more senior doctor in – they are a GP who has worked in the town for some time
• There is no-one with advanced airway skills immediately available
• The small ED is set up with basic drugs and basic airway equipment. You are able to perform basic resuscitation
• There is no blood stored at your hospital – the usual procedure is for it to be brought with a retrieval team
• You are able to run basic lab tests including a VBG, FBE, UEC and coags
• You do have some TXA

The situation
• You have an 80y.o. gentleman who has presented with epistaxis
• History
o Epistaxis for 2 hours
o Spontaneous onset. Blood loss ++ onto towels.
o Bleeding from both nostrils and down back of throat
• Has been coughing/vomiting up small amounts of blood
o He is on warfarin for AF
o No previous history of epistaxis. INR levels usually within normal levels.
o Recent LRTI symptoms – commenced oral antibiotics 5 days ago
• Exam
o BP 180/110 PR 110 RR 16 SpO2 95% Temp 36.4
o Bleeding from both nostrils and down back of throat
o No obvious trauma
o Chest clear
o No obvious airway compromise
• Investigation
o VBG:
• pH 7.30 HCO3 20 pCO2 38
• Hb 85
• Na+ 140 K+ 4.5 Cl 90
o FBE, UEC, Coags – pending
• What you have tried so far:
o External compression for 10 mins
o Merocell nasal tampons in both nostrils
• Despite this he continues to bleed.


Your questions to the candidate
• What can I do now to stop the bleeding?
o If prompted: no anterior source of bleeding seen
o No rapid rhino available. Does have Foley catheter
o Once foley catheter or posterior packing completed bleeding appears to cease
• If required
o Are there any other treatments I can give? (if fluids/resuscitation not yet discussed)
o What should I do about his BP?
o Should I arrange transport to you? (If disposition not discussed)

For the examiner

telephone station
see assessment for further details

Domains Assessment Objectives

Medical Expertise
Identifies likely posterior bleed
Identifies possibility of warfarin over-anticoagulation
Stepwise management plan, including
- Resus
o IV fluids, large bore cannula.
o Identifies potential need for blood products
- of epistaxis
o set-up – suction, lighting, PPE
o sit patient upright + slightly forward
o may try cophenylcaine/adrenaline spray/packing ± TXA
o view on anterior nose - ? source bleeding
o decision to posteriorly pack
• Foley catheter or ribbon gauze
- Of BP: manage conservatively, consider treatment if remains high post haemorrhage control

Prioritisation And Decision Making
Identifies potential life threat if bleeding not controlled
Activation of retrieval services

Communication
Establishes clear history and examination findings
Clear step-wise instructions

Health Advocacy
Identifies need for transport to larger centre (posterior bleed, higher risk)

Scholarship and Teaching
Clear instructions
Checks understanding throughout
Supportive

Other Assessment Notes