Module 1

This is the first module of your virtual introduction.
Below you will find Part I and Part II of the introduction to the Video Lectures.
These 2 lectures introduce what the current OSCE exam is about and how you should be thinking of the exam.
They also introduce you to what you will expect to experience on the day, including quarantine and the bells and buzzers scenarios.

My interpretation of the exam is that it is currently  split into 4 main Parts. This understanding allows you to practice what's important to pass:

1. Clinical Examination
   1. Remember that the olde-style patient has now been replaced by a FACEM, or an actor. Real patients aren't used any more. This means that there is only so much they can fake. 
   2. Start to think in terms of what is possible to 'put on' and make sure you know these;
      1. diplopia
      2. scotoma
      3. hemianopia
      4. decreased visual acuity
      5. weakness
      6. sensory loss
      7. normal JVP
      8. .......etc what else can you think of?
2. Mini- Lectures- Teaching- remember to approach the junior doctor with a real want to teach. Find out how much they already know. Teach and then at regular intervals ask for feedback that shows they have understood. Let them ask questions. Given that sometimes the scenario will begin with "This is the ECG of the patient in bed 8"- make sure the patient is stable and ask if anyone is with the patient.
   1. These can include an ECG
      1. The usual suspects
         1. WCT
         2. STEMI
         3. Blocks
         4. Arrhythmias
   2. It can be a procedure- there are a limited number of procedures you need to know.
3. Communication/Explanation
   1. This can be a complaint
   2. It can be an impaired Doctor
   3. It can be something administrative
4. Clinical Management Hands On. This is the simulation. This tests acute management of patients.
   1. Airway- this can be about technique i.e., demonstrate intubation or surgical airway technique. It can be about methods of oxygenation, it can be about medications and the airway. It can even be about sedation
   2. Resuscitation: Think of conditions such as seizure, overdose, cardiac arrest, paediatric arrest and more.
   3. The SOB patient.

The Exam has just changed again from 2018.1 to 2 days and 11 stations, with no double stations. We will go over this in coming weeks. If you see of hear  a reference to the old 3 days etc, it's that the videos haven't been updated on that detail. We will go over this. But that's all thats different. The important thing to remember here is the STRATEGY we teach. The fine details we will get easily. Keep Going!

Introduction Videos

OSCE Part 1 from Peter Kas on Vimeo.

OSCE Part II from Peter Kas on Vimeo.

Try a little OSCE- Do this in real time

This is a simple ECG OSCE. The ECG comes up again and again in the OSCE, so make sure you cover the important ECGs. 

SCENARIO- Read in 3 minutes- this is your outside the room time- then the bell goes off and you go in

You are working as a consultant in a tertiary emergency department, with a junior registrar.
 
You have been called for assistance in interpreting an ECG of a 62 yo male who has presented with 2 hours of palpitations.
 
Your tasks are:
 

1. Describe the ECG to the Registrar and explain your interpretation of the ECG.
   
2. Give a differential diagnosis of the patient’s condition
   
3. Instruct the registrar on appropriate treatment and a management plan for their patient.

 
You will need to provide detailed instructions to the registrar, including doses and administration routes.
 
You will be assessed on:
Your interpretation of the ECG
Appropriate DDx
Communication
Management plans
Teaching skills
 
You will not be required to examine the patient.

THE ECG- look at and discuss after the 3 minutes

The Answer

Always introduce yourself.
Make sure that the patient is stable and that there is someone with the patient.
Establish that you can stay there and do the scenario- you may need to say that we need to see this patient urgently and- this will not happen unless its a SIM. They will have something there to make sure the patient is OKAY.
Ask about the Vitals in this case i.e. BP
-ensure patient in resus and someone with patient
 
Interpretation WCTwith rate of ~150
 
DDx are:
VT
SVT with aberrancy
Hyperkalemia
Na channel blockade
 
How to diagnose VT:
1 Rate and width >120 >0.16ms
2 AV dissociation
3  Capture beats/fusion beats
4 Concordance
5 Brugada Sign- distance from beginning of QRS to s wave > 100ms
6 Josephson’s sign –notch near nadir of s wave

You may be led in this question by being told the patient is harm-dynamically stable.

Your definitive management will be DC cardioversion
sedation- pick your medication and give dosages
ie., apnoea oxygenation
ensure airway equipment checked
consent and explanation to patient
staff understand procedure
ketamine 0.5-1mg /kg
propofol 0.5-1mg/kg
200J single biphasic

Topics of can we give adenosine may be discussed. The answer is as long as the rhythm is regular you can. ig wide and atrial fibrillation- you cannot.

Points for Discussion

its always difficult when doing these by yourself.
The key things to remember in this type of OSCE are:
FIRSTLY- ask about the patient and are they stable. Ask for the vitals.
When you see an ECG like this say something like" This is a wide complex Tachycardia. I am concerned about this patient. Are they in a Resus cubicle and is someone with them. Also, should we be heading there now?"
Usually you will be enough reassurance that you don't need to attend.
Speaking this speak shows that you are aware that this is a potentially nasty ECG.

Then proceed to ascertain the level of knowledge of the junior doctor and how much they understand of the egg in front of them.
Then proceed.
Give differentials
​Ask to see if the junior doctor has understood a point and then progress.

Here is a simple video on diagnosing VT.

VT or not VT Assoc Prof Peter Kas from Peter Kas on Vimeo.

If you want to do a bit more study on ECG's, go to www.resus.com.au and look at ECG of The Week

Watch the 'Rule The Arrhythmia' Webinar for some quick points on reading the ECG

The SIMULATION OSCE
Some Tips that may help

The key is to immerse yourself in the scenario. Everyone is there for your benefit. There are no tricks and no-one is allowed to trick you. They cannot prompt you to stray you from maximum marks, they can only prompt you to give you more marks. Here are a few tips, that may help:

1. ​When you sit outside the room, think of the scenario and possible directions it may take. Think of treatment strategies and keep an open mind. You can be sure they will ask one thing, but don't be thrown off, if they ask another.
2. When you enter the room, look around and see if there are any clues, ECG, Xray, infusion, antibiotics vial.
3. You will usually be greeted in a 'Thank God you're here" fashion. i.e., "Thanks for coming. This is Mrs Smith, a 68 year old woman who presents with....." LISTEN, All the clues are in the stem. The answer is there.
4. Ask for the vitals
5. Always have a set of differentials
6. Lead your team. Designate roles and make sure that those people are up to the task. Also, designate appropriately. If you are given a senior registrar that will work with you, use their skill set appropriately i.e., don't get them to put in a cannula if airway is not looked after.This is a prioritisation and leadership issue. In a recent OSCE exam, the registrar(who was actually a FACEM), was asked to perform a task(put in an IV). He then asked the delegate, "Do you think this is the best use of me?" The delegate thinking quickly said "No, you're right, I think you should be managing ....." If you do get this, the examiner is trying to help you, listen and ADAPT. Most importantly never argue with an examiner.
7. You will be prompted by those in the room, but only if this has been pre-determined. There is of course some allowance for human error here, however if prompting is an option, it will occur in relation to a specific event.
8. If you have a nurse with you, their usual brief is that they are a competent nurse that can get whatever is needed, however they have specific instructions that they cannot offer suggestions (or will have instructions to offer a suggestion in a prompt), like you normally might get in the real situation at work.
9. If you are asked "Are you sure you want to..........?" Rethink What you've just said.
10. Sometimes questions are asked because they haven't heard, or they want to make sure that they have heard an answer, or a dose, or something else. If this happens rethink, "Have I just said something that will harm the patient?" If not repeat what you said.                                                                                                  

Try a little OSCE(supplied by other source, but good to try)

SCENARIO- 3 minutes

You are the consultant in a metropolitan ED. An intern asks for assistance with a blood gas from a recently arrived 12 year old patient.
 
Your tasks are to:

• Interpret and explain the blood gas 
• Explain in detail the next steps in this patient’s investigation and management will be

 
You are NOT required to review the patient in this scenario.
 
Assessment Criteria

• Medical Expertise
• Teaching & Scholarship

The ABG

​pH                   7.05
pCO2              23
pO2                 40
HCO3             10
Na                   125
Cl                    98
K                     5.0                  
Lact                 3.4
Gluc                65.5

ANSWER

VBG INTERPRETATION
Metabolic Acidosis/HAGMA
Secondary to DKA
Consistent with presentation
 
Resp compensation appropriate .
Expected CO2 = (1.5 x 10) + 8 (+/-2) = 23
 
Raised AG = 22
Delta Ratio = change in AG/change in Bic = (22-10)/(24-12) – 12/12 = 1
No additional acid base disturbance
 
Corrected Na = 125 + (65.5-5.5)/3 = 145
NOT hypernatraemic
 
Potassium at upper range of normal –not yet requiring addition to the IVF
Expect potassium to fall as acidosis corrected – 0.5mmol for every 0.1 units pH = 0.5 x 3.5 = 1.75 mmol. Potassium likely to fall to 3.25

Fluid replacement with normal saline and potassium

• Around 150mlhr of saline + potassium
• Caution with potassium replacement – likely whole body deplete, but if measured K >5.5 need to wait for urine to be passed or K <5.5)
  • Potassium replacement starts at (40-60mmol/L)
  • Potassium level should be checked hourly initially
• If the blood glucose falls very quickly within the first few hours, or if the BGL reaches 12-15mmol/l, change to normal saline with 5% dextrose and potassium.

 
Examiner Notes (cont)
 
Insulin

• Add 50 units of clear/rapid-acting insulin (Actrapid HM or Humulin R) to 49.5 ml 0.9% NaCl (1 unit/ml solution).

• Start rates:
• 0.1 units/kg/hr as glucose levels > 15 mmol/l.
  • Aim to keep the blood glucose level between 5 - 12mmol/l.
• The insulin infusion can be discontinued when the child is alert and metabolically stable (pH > 7.30 and HCO3 > 15). The best time to change to s.c. insulin is just before meal time. The insulin infusion should only be stopped 30 minutes after the first s.c. injection of rapid-acting insulin.

Ongoing monitoring and management

• Likely HDU admission
• Strict fluid balance
• Hourly observations
• Hourly glucose and blood ketones measurement
• Re-check K+ within one hour of commencing insulin infusion
• Venous blood gas and lab glucose 2 hourly

Bicarbonate
Bicarbonate administration is not routinely recommended as it may cause paradoxical CNS acidosis.
 
 Cerebral Oedema
Some degree of subclinical brain swelling is present during most episodes of diabetic ketoacidosis. Clinical cerebral oedema occurs suddenly, usually between 6 and 12 hours after starting therapy (range 2 - 24 hr). Mortality or severe morbidity is very high without early treatment.
Prevention
Slow correction of fluid and biochemical abnormalities. Optimally, the rate of fall of blood glucose and serum osmolality should not exceed 5 mmol/l/hr, but in children there is often a quicker initial fall in glucose. Patients should be nursed head up.
Warning signs

• Risk factors: first presentation, long history of poor control, young age ( < 5 yr)
• No sodium rise as glucose falls, hyponatraemia during therapy, initial adjusted hypernatraemia

Examiner's Sheet

VOCALIZE and VERBALISE

You need to practice, practice and practice. Up till now you have written everything in the exam. You must now verbalise the answer. For some people, that doesn't come naturally. You have to practice.
May I recommend that you pick 2-3 topics or simply do the topics above again and as you are explaining or expressing yourself, video yourself on your phone and watch it back. Watch the fidgeting and the facial expressions and the slumped shoulders and the look of horror on some faces. Do you look like a confident junior consultant?
Don't worry we'll go over some of this during the Face to Face day.

SOME PHRASES YOU SHOULD PRACTICE HAVING READY: THE SPEAK

• "Is the patient stable and is there someone looking after the patient?"
• "We need to stabilise the patient"
• "Let's make sure the rest of the department is taken care of"
• "Is someone managing the department, whilst I'm in resus?"
• "Is there someone we can contact for you?"
• "I would like to get a nurse to sit with you and explain what we are doing"
• "Before we start, can we get some pain relief for this child"
• "We need to move patients"(In a surge event)

Now get some more of these phrases ready. Remember when you use them they should be appropriate for the situation i.e., not all patients go to the Resus cubicle.

Below is a Checklist

Below is a checklist that I used to teach for the old SAQ, however it also pertains to the new OSCE.