|
To continue the equipment OSCE
To the right, is the video on Ventilators. Watch it, it is 25 minutes worth spending. You may have a Hamilton. It's the principles to think of. |
|
OSCE 1- ECG
Candidates Instructions
Doctor Jones is a PGY3 junior doctor. They wish to discuss a patient’s ECG and their clinical presentation. The history is as follows, but Dr Jones is unaware of the examination findings.
At your tertiary referral centre, it is 11 am on a Wednesday.
The patient, John, is a 40 year old man who is currently in Resus having come in following a syncopal episode without any injury.
The patient is currently stable in the resuscitation room under the care of a senior registrar and therefore you have time and/or several minutes to discuss this with Dr Jones.
Your tasks are to:
This OSCE will assess the following domains:
At your tertiary referral centre, it is 11 am on a Wednesday.
The patient, John, is a 40 year old man who is currently in Resus having come in following a syncopal episode without any injury.
The patient is currently stable in the resuscitation room under the care of a senior registrar and therefore you have time and/or several minutes to discuss this with Dr Jones.
Your tasks are to:
- · Interpret the ECG
- · Discuss the potential causes for the patient’s presentation
- · Explain what investigations would be required
- Discuss the options for the circumstance of the patient deteriorating.
This OSCE will assess the following domains:
- · Medical Expertise
- · Scholarship & Teaching
Role players instructions
Junior Doctor ROLE-PLAYER INSTRUCTIONS
You will be playing the role of a junior (PGY3) doctor currently working in the ED. You have just seen John, a 40 year-old man who is currently in Resus having come in following a syncopal episode at home. John had an AMI just over 6 months and today he describes an episode where he simply lost consciousness. He has recently been feeling lethargic.
You have been in the resuscitation room with the senior registrar. You have heard the history and have just seen his initial ECG. The patient is stable and in good hands with the senior registrar, who is going about an examination and further assessment. You are seeking guidance about the ECG interpretation in this setting. You are also wondering what could cause this, as well as how to further investigate.
As a junior doctor you recognise that there is a bradycardia but are having trouble working out the exact rhythm and what to look for on the ECG in this presentation.
The Candidate will Walk into the Room:
‘Hi I’m Dr Jones, Thanks for helping me with this case’ ... Sit down and show the ECG to the candidate such that a discussion can begin.
While the candidate starts to look at the ECG, reiterate the history as above:
‘I’ve just seen John, a 40 year-old man who is currently in Resus. He has come in following a syncopal episode at home. John had an AMI 6 months ago. I have been in the resuscitation room with Jack, the senior registrar. Jack is sorting it. The patient is stable and in good hands. I was wondering if you could help me interpret this ECG and have a quick chat about the case please’
The candidate will likely firstly ascertain your baseline knowledge about the ECG. The following should be the response:
‘Well, there is bradycardia with a rate about 50 but I can’t quite work out the rhythm.’
Your base line knowledge includes simple ECG interpretation and a rudimentary differential diagnosis (myocardial ischaemia and drugs). You recognise the left bundle branch pattern, but not the CHB. You recognise that there are p waves on the ECG.
You may be asked about an old ECG but at this point ‘I don’t have the chart’.
You need to get the candidate to explore the relevant relative negatives and positives on the ECG. The candidate must describe and explain clearly to you the following points:
1. Complete heart block: p waves independent from QRS
2. Escape rhythm 40/min with LBBB morphology: Rate and morphology suggest coming from infranodal conducting tissue
If necessary, ask ‘So what is happening with the QRS?’ and ‘Where is it coming from?’
‘What else should I be looking for on the ECG?’ They may discuss looking for signs of ischaemia, hyperkalaemia etc.
You are an ALS provider and are familiar with the treatment of symptomatic bradyarrthymias and therefore do not require a discussion on this.
‘I am happy with the management of symptomatic bradycardia’
You are also focused on learning about how you differentiate heart blocks.
‘How do I differentiate types of heart block?’
First Degree Heart Block: Prolonged PR
Second degree heart block: Mobitz I and II- what happens to PR
The interpretation and teaching with the ECG should take around 4 minutes, and you can move on at the 4 minute mark if the ECG interpretation seems adequate or exhausted. Poor candidates may struggle to relay information and take longer. Similarly, good candidates may have a lot of information to relay and start talking about Sgarbossa criteria. If time is running out to 5 minutes, do not use any more prompts or dialogue that would prolong the ECG discussion.
Then the discussion needs to move to possible causes, investigations and acute management in case of deterioration, might be required.
‘What causes do we need to consider in him? How should we investigate for them?’
The candidate may well say to you what do you think the causes could be. In response to this say something like
‘ACS perhaps.... I’m not really sure though’
The candidate should outline a number of potential causes
Ischaemia ,Drugs (BBlockers, Amiodarone, CaCB), Degenerative, Cardiac disease (myocarditis / infiltration), Electrolyte (HyperK+)
Then proceed to prompting about investigations. If asked, you can suggest some basic investigations such as FBE/ UEG/LFT and TnI.
‘Are there any other tests that we should get?’
‘Should we get the patient to the cath lab for an angiogram?’
The move the candidate on to discussion about what would happen if the rate decreased or the blood pressure decreased further by asking
“What should we do if his blood pressure started falling?
The candidate should then discuss options of; Medical vs electrical treatment
The patient will need a definitive pacemaker but interim measures would be.
Medical:
Atropine, adrenaline, isoprenaline(drug of choice)
Electrical:
If not responding to these need to sedate and consider external cardiac pacing:
Explain the procedure:
Consent
Analgesia and sedation Ketamine good drug for this
Apply leads to read rhythm
Switch pacing mode on and increase current until capture occurs.
Continue until not able to tolerated- then can float a wire ie transvenous pacing.
You will be playing the role of a junior (PGY3) doctor currently working in the ED. You have just seen John, a 40 year-old man who is currently in Resus having come in following a syncopal episode at home. John had an AMI just over 6 months and today he describes an episode where he simply lost consciousness. He has recently been feeling lethargic.
You have been in the resuscitation room with the senior registrar. You have heard the history and have just seen his initial ECG. The patient is stable and in good hands with the senior registrar, who is going about an examination and further assessment. You are seeking guidance about the ECG interpretation in this setting. You are also wondering what could cause this, as well as how to further investigate.
As a junior doctor you recognise that there is a bradycardia but are having trouble working out the exact rhythm and what to look for on the ECG in this presentation.
The Candidate will Walk into the Room:
‘Hi I’m Dr Jones, Thanks for helping me with this case’ ... Sit down and show the ECG to the candidate such that a discussion can begin.
While the candidate starts to look at the ECG, reiterate the history as above:
‘I’ve just seen John, a 40 year-old man who is currently in Resus. He has come in following a syncopal episode at home. John had an AMI 6 months ago. I have been in the resuscitation room with Jack, the senior registrar. Jack is sorting it. The patient is stable and in good hands. I was wondering if you could help me interpret this ECG and have a quick chat about the case please’
The candidate will likely firstly ascertain your baseline knowledge about the ECG. The following should be the response:
‘Well, there is bradycardia with a rate about 50 but I can’t quite work out the rhythm.’
Your base line knowledge includes simple ECG interpretation and a rudimentary differential diagnosis (myocardial ischaemia and drugs). You recognise the left bundle branch pattern, but not the CHB. You recognise that there are p waves on the ECG.
You may be asked about an old ECG but at this point ‘I don’t have the chart’.
You need to get the candidate to explore the relevant relative negatives and positives on the ECG. The candidate must describe and explain clearly to you the following points:
1. Complete heart block: p waves independent from QRS
2. Escape rhythm 40/min with LBBB morphology: Rate and morphology suggest coming from infranodal conducting tissue
If necessary, ask ‘So what is happening with the QRS?’ and ‘Where is it coming from?’
‘What else should I be looking for on the ECG?’ They may discuss looking for signs of ischaemia, hyperkalaemia etc.
You are an ALS provider and are familiar with the treatment of symptomatic bradyarrthymias and therefore do not require a discussion on this.
‘I am happy with the management of symptomatic bradycardia’
You are also focused on learning about how you differentiate heart blocks.
‘How do I differentiate types of heart block?’
First Degree Heart Block: Prolonged PR
Second degree heart block: Mobitz I and II- what happens to PR
The interpretation and teaching with the ECG should take around 4 minutes, and you can move on at the 4 minute mark if the ECG interpretation seems adequate or exhausted. Poor candidates may struggle to relay information and take longer. Similarly, good candidates may have a lot of information to relay and start talking about Sgarbossa criteria. If time is running out to 5 minutes, do not use any more prompts or dialogue that would prolong the ECG discussion.
Then the discussion needs to move to possible causes, investigations and acute management in case of deterioration, might be required.
‘What causes do we need to consider in him? How should we investigate for them?’
The candidate may well say to you what do you think the causes could be. In response to this say something like
‘ACS perhaps.... I’m not really sure though’
The candidate should outline a number of potential causes
Ischaemia ,Drugs (BBlockers, Amiodarone, CaCB), Degenerative, Cardiac disease (myocarditis / infiltration), Electrolyte (HyperK+)
Then proceed to prompting about investigations. If asked, you can suggest some basic investigations such as FBE/ UEG/LFT and TnI.
‘Are there any other tests that we should get?’
‘Should we get the patient to the cath lab for an angiogram?’
The move the candidate on to discussion about what would happen if the rate decreased or the blood pressure decreased further by asking
“What should we do if his blood pressure started falling?
The candidate should then discuss options of; Medical vs electrical treatment
The patient will need a definitive pacemaker but interim measures would be.
Medical:
Atropine, adrenaline, isoprenaline(drug of choice)
Electrical:
If not responding to these need to sedate and consider external cardiac pacing:
Explain the procedure:
Consent
Analgesia and sedation Ketamine good drug for this
Apply leads to read rhythm
Switch pacing mode on and increase current until capture occurs.
Continue until not able to tolerated- then can float a wire ie transvenous pacing.
examiners instructions
You are to observe the candidate only. You may re-orientate the candidate to the tasks if they get off track.
Up to 5 minutes should be allowed for ECG interpretation and the rest of the time for case base discussion with the RMO about the possible causes and investigations and acute treatment in case of deterioration.
This OSCE will assess the following domains:
Up to 5 minutes should be allowed for ECG interpretation and the rest of the time for case base discussion with the RMO about the possible causes and investigations and acute treatment in case of deterioration.
This OSCE will assess the following domains:
- · Medical Expertise
- · Scholarship & Teaching
OSCE 2- ECG
candidates instructions
CANDIDATE INSTRUCTIONS Group Mark
Doctor Jones is a PGY3 junior doctor. He wishes to discuss a patient’s ECG and their clinical presentation. The history is as follows, but Dr Jones is unaware of the examination findings.
At your tertiary referral centre, it is 11 am on a Wednesday.
The patient, Mary, is a 68 year old woman who is currently in Resus has come in with a complaint of increasing shortness of breath. She has a cardiac history and has had a CABG 3 weeks ago. She also has hypertension and NIDDM, but is otherwise very well.
The patient is currently stable in the resuscitation room under the care of a senior registrar and therefore you have time and/or several minutes to discuss this with Dr Jones.
Your tasks are to:
· Interpret the ECG
· Discuss the potential causes for the patient’s presentation
· Explain what investigations would be required
You are not required to take a further history. Management is not a focus of this OSCE.
This OSCE will assess the following domains:
· Medical Expertise
· Scholarship & Teaching
Doctor Jones is a PGY3 junior doctor. He wishes to discuss a patient’s ECG and their clinical presentation. The history is as follows, but Dr Jones is unaware of the examination findings.
At your tertiary referral centre, it is 11 am on a Wednesday.
The patient, Mary, is a 68 year old woman who is currently in Resus has come in with a complaint of increasing shortness of breath. She has a cardiac history and has had a CABG 3 weeks ago. She also has hypertension and NIDDM, but is otherwise very well.
The patient is currently stable in the resuscitation room under the care of a senior registrar and therefore you have time and/or several minutes to discuss this with Dr Jones.
Your tasks are to:
· Interpret the ECG
· Discuss the potential causes for the patient’s presentation
· Explain what investigations would be required
You are not required to take a further history. Management is not a focus of this OSCE.
This OSCE will assess the following domains:
· Medical Expertise
· Scholarship & Teaching
role players instructions
ROLE-PLAYER INSTRUCTIONS
You will be playing the role of a junior (PGY3) doctor currently working in the ED. You have just seen Mary a 68 yo woman who is currently in Resus having come in from home with increasing shortness of breath.
You have been in the resuscitation room with the senior registrar. You have heard the history and have just seen her initial ECG. The patient is stable and in good hands with the senior registrar, who is going about an examination and further assessment.
You are seeking guidance about the ECG interpretation in this setting. You are also wondering what could cause this, as well as how to further investigate.
As a junior doctor you recognise that there is a tachycardia but are having trouble working out the exact rhythm and what to look for on the ECG in this presentation.
The Candidate will Walk into the Room:
‘Hi I’m Dr Jones, Thanks for helping me with this case’ ... Sit down and show the ECG to the candidate such that a discussion can begin.
While the candidate starts to look at the ECG, reiterate the history as above:
‘I’ve just seen Mary, a 68 yo woman who is currently in Resus. She has come in following increasing shortness of breath. She has had bypass grafting 3 weeks ago, but apart from that is well, with only hypertension and NIDDM and lives at home. I have been in the resuscitation room with Jack, the senior registrar. Jack is sorting it. The patient is stable and in good hands. I was wondering if you could help me interpret this ECG and have a quick chat about the case please’
The candidate will likely firstly ascertain your baseline knowledge about the ECG. The following should be the response:
‘Well, there is tachycardia with a rate about 150 but I can’t quite work out the rhythm.’
Your base line knowledge includes simple ECG interpretation and a rudimentary differential diagnosis (myocardial ischaemia and drugs). You recognise the rate is fast, but don’t know the cause.
You may be asked about an old ECG but at this point ‘I don’t have the chart’.
You need to get the candidate to explore the relevant relative negatives and positives on the ECG. The candidate must describe and explain clearly to you the following points:
1. Electrical alternans
2. Tachycardia and recent history may mean a pericardial effusion.
If necessary, ask ‘So what is happening with the QRS?’
‘What else should I be looking for on the ECG?’
They may discuss looking for signs of ischaemia, etc.
You are an ALS provider and are familiar with the treatment of symptomatic tachyarrhythmias and therefore do not require a discussion on this.
‘I am happy with the management of tachycardia. Is there a particular type of tachycardia, I should be looking for?’
The candidate needs to explain electrical alternans and the causes of it.
The candidate also needs to mention that the tachycardia may be an SVT, and needs to see if it changes.
If explanations by the candidate are not clear to you please ask for clarification and/or say ‘I don’t understand’.
The interpretation and teaching with the ECG should take around 4 minutes, and you can move on at the 4 minute mark if the ECG interpretation seems adequate or exhausted. Poor candidates may struggle to relay information and take longer. Similarly, good candidates may have a lot of information to relay. If time is running out to 5 minutes, do not use any more prompts or dialogue that would prolong the ECG discussion.
Then the discussion needs to move to possible causes and what investigations might be required.
‘What causes do we need to consider in her? How should we investigate for them?’
The candidate may well say to you what do you think the causes could be. In response to this say something like
‘ACS perhaps.... I’m not really sure though’
The candidate should outline a number of potential causes :
ECHO
Bloods including FBC, EUC, LFT, COAGS
CXR
May need emergency drainage.
You will be playing the role of a junior (PGY3) doctor currently working in the ED. You have just seen Mary a 68 yo woman who is currently in Resus having come in from home with increasing shortness of breath.
You have been in the resuscitation room with the senior registrar. You have heard the history and have just seen her initial ECG. The patient is stable and in good hands with the senior registrar, who is going about an examination and further assessment.
You are seeking guidance about the ECG interpretation in this setting. You are also wondering what could cause this, as well as how to further investigate.
As a junior doctor you recognise that there is a tachycardia but are having trouble working out the exact rhythm and what to look for on the ECG in this presentation.
The Candidate will Walk into the Room:
‘Hi I’m Dr Jones, Thanks for helping me with this case’ ... Sit down and show the ECG to the candidate such that a discussion can begin.
While the candidate starts to look at the ECG, reiterate the history as above:
‘I’ve just seen Mary, a 68 yo woman who is currently in Resus. She has come in following increasing shortness of breath. She has had bypass grafting 3 weeks ago, but apart from that is well, with only hypertension and NIDDM and lives at home. I have been in the resuscitation room with Jack, the senior registrar. Jack is sorting it. The patient is stable and in good hands. I was wondering if you could help me interpret this ECG and have a quick chat about the case please’
The candidate will likely firstly ascertain your baseline knowledge about the ECG. The following should be the response:
‘Well, there is tachycardia with a rate about 150 but I can’t quite work out the rhythm.’
Your base line knowledge includes simple ECG interpretation and a rudimentary differential diagnosis (myocardial ischaemia and drugs). You recognise the rate is fast, but don’t know the cause.
You may be asked about an old ECG but at this point ‘I don’t have the chart’.
You need to get the candidate to explore the relevant relative negatives and positives on the ECG. The candidate must describe and explain clearly to you the following points:
1. Electrical alternans
2. Tachycardia and recent history may mean a pericardial effusion.
If necessary, ask ‘So what is happening with the QRS?’
‘What else should I be looking for on the ECG?’
They may discuss looking for signs of ischaemia, etc.
You are an ALS provider and are familiar with the treatment of symptomatic tachyarrhythmias and therefore do not require a discussion on this.
‘I am happy with the management of tachycardia. Is there a particular type of tachycardia, I should be looking for?’
The candidate needs to explain electrical alternans and the causes of it.
The candidate also needs to mention that the tachycardia may be an SVT, and needs to see if it changes.
If explanations by the candidate are not clear to you please ask for clarification and/or say ‘I don’t understand’.
The interpretation and teaching with the ECG should take around 4 minutes, and you can move on at the 4 minute mark if the ECG interpretation seems adequate or exhausted. Poor candidates may struggle to relay information and take longer. Similarly, good candidates may have a lot of information to relay. If time is running out to 5 minutes, do not use any more prompts or dialogue that would prolong the ECG discussion.
Then the discussion needs to move to possible causes and what investigations might be required.
‘What causes do we need to consider in her? How should we investigate for them?’
The candidate may well say to you what do you think the causes could be. In response to this say something like
‘ACS perhaps.... I’m not really sure though’
The candidate should outline a number of potential causes :
- Low QRS voltage
- Electrical Alternans may be caused by:
- Must pick the most likely cause is a pericardial effusion and the patient requires an urgent ECHO
- Other causes of electrical alternans are:
- One important thing to consider here is that the patient has had recent cardiac surgery.
- They may discuss the potential for a PE
ECHO
Bloods including FBC, EUC, LFT, COAGS
CXR
May need emergency drainage.
examiners instructions
OSCE 3- EQUIPMENT
candidates instructions
OSCE 4 GROUP MARK
CANDIDATE INSTRUCTIONS
You are working in a Tertiary ED with a junior registrar.
You have been asked to assist the registrar by describing the workings of the defibrillator.
You are to:
You will not be required to demonstrate the equipment or perform a procedure.
Areas of the Curriculum examined
CANDIDATE INSTRUCTIONS
You are working in a Tertiary ED with a junior registrar.
You have been asked to assist the registrar by describing the workings of the defibrillator.
You are to:
- Describe the equipment and how it functions
- Instruction of appropriate settings
- Explanation of the ways it can be used in the ED
You will not be required to demonstrate the equipment or perform a procedure.
Areas of the Curriculum examined
- Medical Expertise
- Communication
- Teaching skills
role players instructions
ROLE PLAYER INSTRUCTIONS
You have seen, but never used a defibrillator before.
You want to know what each button does and what settings to use
If with 1.5 minutes to go the candidate has not answered- you need to ask about pacer and about sync, complications, success rate.
You have seen, but never used a defibrillator before.
You want to know what each button does and what settings to use
If with 1.5 minutes to go the candidate has not answered- you need to ask about pacer and about sync, complications, success rate.
examiners instructions
OSCE 4- CLINICAL EXAMINATION
CANDIDATES INSTRUCTIONS
CANDIDATE INSTRUCTIONS
A 43 yo male has presented with an ongoing issue of weakness in his right hand. The junior resident has asked you to examine the hand and assist in determining what the issue is.
Please examine the patient’s hand and identify possible causes.
You can examine the patient and ask them to perform certain movement, but you cannot ask questions on history.
You will be assessed on:
This OSCE assesses the Domains of:
A 43 yo male has presented with an ongoing issue of weakness in his right hand. The junior resident has asked you to examine the hand and assist in determining what the issue is.
Please examine the patient’s hand and identify possible causes.
You can examine the patient and ask them to perform certain movement, but you cannot ask questions on history.
You will be assessed on:
- Your examination technique
- Your identification of the causes
This OSCE assesses the Domains of:
- Medical Expertise
- Communication
ROLE PLAYERS INSTRUCTIONS
You will maintain your hand position in the sign of the Benediction.
EXAMINERS INSTRUCTIONS
OSCE 5- CLINICAL EXAMINATION
candidates instructions
CANDIDATE INSTRUCTIONS
You have been asked to see a 72 year old gentleman whose family have brought him in with the concern that he is more confused than normal.
The registrar has performed a full cardiac and respiratory and gastro examination, with no findings. He has also examined upper and lower limbs and cranial nerves neurologically. They are all normal, with perhaps some minor weakness on the patients right.
He has asked you for assistance with demonstrating a higher centres exam.
You will be required to:
You are not permitted to ask the patient any questions in relation to history
The OSCE will examine the DOMAINS of:
You have been asked to see a 72 year old gentleman whose family have brought him in with the concern that he is more confused than normal.
The registrar has performed a full cardiac and respiratory and gastro examination, with no findings. He has also examined upper and lower limbs and cranial nerves neurologically. They are all normal, with perhaps some minor weakness on the patients right.
He has asked you for assistance with demonstrating a higher centres exam.
You will be required to:
- Examine the patient and demonstrate signs
- Determine if there is an issue and identify its location
You are not permitted to ask the patient any questions in relation to history
The OSCE will examine the DOMAINS of:
- Medical Expertise
- Communication
role players instructions
ROLE PLAYER
You can do everything except:
You can do everything except:
- left right finger agnosia and
- acalculia and
- agraphism and
- asteriognosis
examiners instructions
•ORIENTATION – Time and Place
•SPEECH – Handedness (most are R handed, so left dominant)
• DYSPHASIA (dominant)
•Can they understand and follow commands?
•Touch your left ear with right index finger( Parietal)
•Name this object(pen)-nominal
•Say “No ands ifs or buts”
•Read and write
• DYSARTHRIA
•Peter piper picked a pen of pickled peppers
•Baby hippopotamus
•Ta / Ka / Pa
• DYSPHONIA- quality of voice
•If any abnormality of orientation or dysphasia- lobes
FRONTAL
•Reflexes- grasp, pout, glabella tap
“A rolling stone gathers no moss”
Gait- wide base shuffling
TEMPORAL
Memory
Long- when did WWII end?
Remember 3 things - book, gorilla, skyscraper
PARIETAL
• Dominant
•Acalculia
•Agraphism
•Left right finger gnosia
• Dominant/Non-Dominant
•Inatention- which finger moves
•Steriognosis
•Disgraphasthesia
• Non-Dominant
•Apraxia
•Dressing
•Ideational- play violin, comb hair
•Constructional
•draw house
•clock face – right lesion leaves out left side
•SPEECH – Handedness (most are R handed, so left dominant)
• DYSPHASIA (dominant)
•Can they understand and follow commands?
•Touch your left ear with right index finger( Parietal)
•Name this object(pen)-nominal
•Say “No ands ifs or buts”
•Read and write
• DYSARTHRIA
•Peter piper picked a pen of pickled peppers
•Baby hippopotamus
•Ta / Ka / Pa
• DYSPHONIA- quality of voice
•If any abnormality of orientation or dysphasia- lobes
FRONTAL
•Reflexes- grasp, pout, glabella tap
“A rolling stone gathers no moss”
Gait- wide base shuffling
TEMPORAL
Memory
Long- when did WWII end?
Remember 3 things - book, gorilla, skyscraper
PARIETAL
• Dominant
•Acalculia
•Agraphism
•Left right finger gnosia
• Dominant/Non-Dominant
•Inatention- which finger moves
•Steriognosis
•Disgraphasthesia
• Non-Dominant
•Apraxia
•Dressing
•Ideational- play violin, comb hair
•Constructional
•draw house
•clock face – right lesion leaves out left side
OSCE 6- THE IMPAIRED DOCTOR
candidates instructions
CANDIDATE INSTRUCTIONS
You are a new consultant working in a tertiary hospital. Your evening consultant, who takes over from you, is several hours late for his shift.
You ask the Department secretary to call and make sure he is OK and that he knows about the shift as he has not called in sick, and you don’t know him personally.
The secretary comes out and is upset as he has been yelling at her on the phone for calling him.
You cannot discuss this immediately with your Director as it is his rostered day off.
The consultant arrives and yells loudly in the Department; “Who the fuck asked the secretary to call me?”
When you answer that it was you, he approaches you in an aggressive manner and continues to speak to you in a loud and aggressive voice.
You let the consultant know that this is not the right environment for this discussion and ask to see him privately in a consultant’s office.
You have told the consultant that you don’t appreciate being yelled at and were simply concerned that he did not know about his shift or that he was OK, being so late.
You also notice that he smells of alcohol and looks somewhat inebriated.
The OSCE will examine the Domains of:
You are a new consultant working in a tertiary hospital. Your evening consultant, who takes over from you, is several hours late for his shift.
You ask the Department secretary to call and make sure he is OK and that he knows about the shift as he has not called in sick, and you don’t know him personally.
The secretary comes out and is upset as he has been yelling at her on the phone for calling him.
You cannot discuss this immediately with your Director as it is his rostered day off.
The consultant arrives and yells loudly in the Department; “Who the fuck asked the secretary to call me?”
When you answer that it was you, he approaches you in an aggressive manner and continues to speak to you in a loud and aggressive voice.
You let the consultant know that this is not the right environment for this discussion and ask to see him privately in a consultant’s office.
You have told the consultant that you don’t appreciate being yelled at and were simply concerned that he did not know about his shift or that he was OK, being so late.
You also notice that he smells of alcohol and looks somewhat inebriated.
The OSCE will examine the Domains of:
- Medical Expertise
- Prioritisation and Decision Making
- Communication
role players instructions
You like your job and want to keep doing it. You also like working with the people there. You agree that it was not to yell the way you did.
“I apologise, you are right, I shouldn’t have reacted that way”
Over the last few months you find it harder to come to work. You don’t enjoy work.
You just don’t care and everything is annoying you. There are a lot of things happening outside work.
Your marriage is breaking up and the divorse is a little messy. Your father is in hospital at the moment with pneumonia. You keep asking
“Why do I need to do this”
You also find that you have been drinking more to get by. Every night after work you’re drinking 1-2 bottles of wine and sometimes just forget when shifts are on.
You cant sleep without the drinking and you are just feeling down.
There is no interest in anything. I used to love walking the dog and going to the movies, I just don’t care now.
“I’ve even thought of ending it all sometimes, but won’t do anything”
“I’m really sorry. I realise what this looks like.
I will get help I promise, just please keep this between us, I don’t want to lose my job as I have a mortgage and I just couldn’t take it if that happened”
My son supports me and I love him and could just take the day off and get myself sorted. He can pick me up.
The interaction continues…..
“I apologise, you are right, I shouldn’t have reacted that way”
Over the last few months you find it harder to come to work. You don’t enjoy work.
You just don’t care and everything is annoying you. There are a lot of things happening outside work.
Your marriage is breaking up and the divorse is a little messy. Your father is in hospital at the moment with pneumonia. You keep asking
“Why do I need to do this”
You also find that you have been drinking more to get by. Every night after work you’re drinking 1-2 bottles of wine and sometimes just forget when shifts are on.
You cant sleep without the drinking and you are just feeling down.
There is no interest in anything. I used to love walking the dog and going to the movies, I just don’t care now.
“I’ve even thought of ending it all sometimes, but won’t do anything”
“I’m really sorry. I realise what this looks like.
I will get help I promise, just please keep this between us, I don’t want to lose my job as I have a mortgage and I just couldn’t take it if that happened”
My son supports me and I love him and could just take the day off and get myself sorted. He can pick me up.
The interaction continues…..
examiners instructions
OSCE 7- COMMUNICATION WITH PARENT
CANDIDATES INSTRUCTIONS
Doctor Jones is a PGY3 junior doctor. He has asked you as the consultant on the shift to assist him with a patient who is insisting a CT Brain be done on her child.
The history is as follows.
At your tertiary referral centre, it is 11 am on a Wednesday.
The patient, Johnny, is a 4 year old who is currently in a cubicle having been sent in by the local after he hit his head on the corner of the coffee table. The injury occurred 2 hours ago. His GP had advised the parent that he requires a CT Brain as he was a little subdued for a minute or two after the accident and now has a bruise on the forehead measuring 3cmm in diameter. There is nothing to find on examination. He has no other past medical history and is on no medications. He is currently happily playing on his parent’s mobile phone.
The patient is currently stable and under the care of a senior registrar and therefore you have time and/or several minutes to discuss this case with Dr Jones. Also Dr Jones has asked that you discuss this with the father who is insisting he gets a CT Brain and insisting he speaks with a senior consultant.
Your tasks are to assist the junior doctor to understand:
The risk stratification of head injury in children
Explain the various methods/scores to rule out severe head injury
To explain the relative risks to the parent
This OSCE will assess:
The history is as follows.
At your tertiary referral centre, it is 11 am on a Wednesday.
The patient, Johnny, is a 4 year old who is currently in a cubicle having been sent in by the local after he hit his head on the corner of the coffee table. The injury occurred 2 hours ago. His GP had advised the parent that he requires a CT Brain as he was a little subdued for a minute or two after the accident and now has a bruise on the forehead measuring 3cmm in diameter. There is nothing to find on examination. He has no other past medical history and is on no medications. He is currently happily playing on his parent’s mobile phone.
The patient is currently stable and under the care of a senior registrar and therefore you have time and/or several minutes to discuss this case with Dr Jones. Also Dr Jones has asked that you discuss this with the father who is insisting he gets a CT Brain and insisting he speaks with a senior consultant.
Your tasks are to assist the junior doctor to understand:
The risk stratification of head injury in children
Explain the various methods/scores to rule out severe head injury
To explain the relative risks to the parent
This OSCE will assess:
- Medical Expertise
- Scholarship and Teaching
- Communication
ROLE PLAYERS INSTRUCTIONS
ROLE-PLAYER 1 INSTRUCTIONS- DR JONES
You will be playing the role of a junior (PGY3) doctor currently working in the ED. You have just seen Johnny, a 4 year-old in a cubicle having come in following a head injury.
You have been in the cubicle with the senior registrar. You have heard the history and have seen the registrar conduct the physical examination. The patient is stable and in good hands with the senior registrar, who is going about a further assessment. The patient has come via the GP who has asked for a CT Brain, that his father is insisting on. You are seeking guidance about the need for a CT Brian in this setting. You are also wondering what an approach would be and if we need to to further investigate.
The Candidate will Walk into the Room:
‘Hi I’m Dr Jones, Thanks for helping me with this case’ ... Sit down and reiterate the history as above:
‘I’ve just seen Johnny, a 4 year-old boy who is currently in the paeds cubicle. He has come in from his GP following a head injury at home. His GP has told Johnny’s parent that he would need a CT Brain and has sent him in. I have been in the cubicle with Jack, the senior registrar. Jack is trying to sort it. The patient is stable and in good hands. I was wondering if you could help me understand how we decide if a child needs a CT head. We may also need you to speak with the parent, as he insists on speaking with the consultant on.’
The candidate will likely firstly ascertain your baseline knowledge about Head injury risk stratification. The following should be the response:
‘Well, there was a head strike and he does have a bruise on the forehead, but Im not sure if he needs an xray or a CT.’
The candidate must explore some specifics:
It would preferential if the candidate discussed the relevant evidence on this:
If explanations by the candidate are not clear to you please ask for clarification and/or say ‘I don’t understand’.
The teaching with the ECG should take around 4 minutes, and you can move on at the 4 minute mark if the discussion seems adequate or exhausted. If time is running out to 5 minutes, do not use any more prompts or dialogue that would prolong the discussion.
After 3 minutes the discussion needs to move to a discussion with the parent.
ROLE PLAYER 2: THE PARENT
You are Johnny’s parent, Mark, a 46 year old professional, who has brought his child in. The story is that you wife is on the way in, following you telling her that Johnny was coming into the ED.
Johnny was playing in the other room. He was running around the room. You then heard a crash and Johnny crying. He ran into the next room where it was obvious that he had run into a table and hit his forehead. You picked him up and he became quiet for about 2 minutes, although awake throughout this time.
After a short while you decided to take him to the GP for review. The GP assessed him and recommended a CT Brain, for which he sent you into the ED.
You will meet with the consultant, where you ask “How long will it be till the CT scan is done?”
You state the GP has asked for one and indicated that we would be going straight in and getting one.
You are allowed to prompt about the risks of the CT vs the risks of a head injury
You will be playing the role of a junior (PGY3) doctor currently working in the ED. You have just seen Johnny, a 4 year-old in a cubicle having come in following a head injury.
You have been in the cubicle with the senior registrar. You have heard the history and have seen the registrar conduct the physical examination. The patient is stable and in good hands with the senior registrar, who is going about a further assessment. The patient has come via the GP who has asked for a CT Brain, that his father is insisting on. You are seeking guidance about the need for a CT Brian in this setting. You are also wondering what an approach would be and if we need to to further investigate.
The Candidate will Walk into the Room:
‘Hi I’m Dr Jones, Thanks for helping me with this case’ ... Sit down and reiterate the history as above:
‘I’ve just seen Johnny, a 4 year-old boy who is currently in the paeds cubicle. He has come in from his GP following a head injury at home. His GP has told Johnny’s parent that he would need a CT Brain and has sent him in. I have been in the cubicle with Jack, the senior registrar. Jack is trying to sort it. The patient is stable and in good hands. I was wondering if you could help me understand how we decide if a child needs a CT head. We may also need you to speak with the parent, as he insists on speaking with the consultant on.’
The candidate will likely firstly ascertain your baseline knowledge about Head injury risk stratification. The following should be the response:
‘Well, there was a head strike and he does have a bruise on the forehead, but Im not sure if he needs an xray or a CT.’
The candidate must explore some specifics:
- Did the child lose consciousness?- no, he cried immediately, but was quiet for a few minutes, subdued.
- What is the conscious state now?
- Where is the injury: Forehead about 3cm diameter
- No other injuries
- Any haemotympanum?
- Any repetitive questioning? Etc
- Questioning a potential cervical injury is important.
It would preferential if the candidate discussed the relevant evidence on this:
If explanations by the candidate are not clear to you please ask for clarification and/or say ‘I don’t understand’.
The teaching with the ECG should take around 4 minutes, and you can move on at the 4 minute mark if the discussion seems adequate or exhausted. If time is running out to 5 minutes, do not use any more prompts or dialogue that would prolong the discussion.
After 3 minutes the discussion needs to move to a discussion with the parent.
ROLE PLAYER 2: THE PARENT
You are Johnny’s parent, Mark, a 46 year old professional, who has brought his child in. The story is that you wife is on the way in, following you telling her that Johnny was coming into the ED.
Johnny was playing in the other room. He was running around the room. You then heard a crash and Johnny crying. He ran into the next room where it was obvious that he had run into a table and hit his forehead. You picked him up and he became quiet for about 2 minutes, although awake throughout this time.
After a short while you decided to take him to the GP for review. The GP assessed him and recommended a CT Brain, for which he sent you into the ED.
You will meet with the consultant, where you ask “How long will it be till the CT scan is done?”
You state the GP has asked for one and indicated that we would be going straight in and getting one.
You are allowed to prompt about the risks of the CT vs the risks of a head injury
EXAMINERS INSTRUCTIONS
You are to observe the candidate only. You may re-orientate the candidate to the tasks if they get off track.
Up to 5 minutes should be allowed for HI discussion and the rest of the time for discussion with the parent.
This OSCE will assess the following domains:
Up to 5 minutes should be allowed for HI discussion and the rest of the time for discussion with the parent.
This OSCE will assess the following domains:
- Medical Expertise
- Scholarship & Teaching
- Communication
