Try this OSCE

Scenario:
A 22/M, has presented to ED via ambulance who picked him with police and has brought him to your tertiary ED. He admits to 2 points of meth over the course of the afternoon and tried to evade the police whilst burglarizing a flat by jumping out of a 1st floor window to flat. The ambulance handover is painful swollen foot and there is note of R foot and ankle swelling and tenderness. They have given a total of 10 mg Morphine IV about 20 minutes ago. Other pertinent exam findings are dilated pupils (6 mm, equal and reactive) and the following obs...

HR 130
BP 125/75
RR 24
SaO2 98% 4L O2
T 37.7 C

Foot xrays were taken and the images are attached.
He is currently in a cubicle in a monitored treatment area.
The police have left but want to be notified if he is for discharge
Instructions for the candidate
Please review the images and on entering the room, perform the following tasks:

1) You have 2 minutes to describe and interpret the images shown to your junior registrar
2) A 5 minute case based discussion will follow around the further assessment and management of this trauma patient
Domains being examined

• Medical Expertise
• Prioritisation And Decision Making

​
​For the examiner
Allow 2 mins for X ray interpretation and prompt to move ion to rest of discussion at 2 mins.
Obs are now
HR now 145
BP 175/85
RR 25
T 38.2 C
SaO2 98% RA
 
You may prompt with:
What other injuries do you suspect?
How will you facilitate further assessment of this patient?
How will you manage him?
The patient is agitated and aggressive and in pain. They are not assessable in the present state and the mechanism is enough to be highly suspicious of multisystem injury.
Attempts to deescalate the patient and provide adequate parenteral opioid analgesia should be initiated early. Anxiolytics with IV or oral benzos should be provided.
The cspine cannot be cleared in the intoxicated patient.

 
Domains Assessment Objectives
Medical Expertise
- Adequate and systematic description and interpretation of foot xrays
--Presence of homolateral Lis Franc fracture dislocation foot
-- An unstable fracture with high risk of midfoot compartment unless managed promptly
-- Pertinent negatives

Unable to clear C spine or head given intoxication
May require intubation and pan scan if non compliant with immobilisation.

- Recognition of sympathomimetic toxicity requiring treatment (benzodiazepines)
-- recognises and verbalises seizure risk, complications such as hyperthermia, rhabdomyolysis

- Considers/rules out differentials for agitation
-- head injury
-- sepsis
-- heat stroke

- Takes measures to ensure patient and staff safety
 
Prioritisation And Decision Making
In management of sympathomimetic syndrome
- Staff and patient safety (i.e, security, considers physical restraint depending level of agitation of actor)
- Benzos
- Fluids
- Preparation for intubation  for ct and management of foot seizures/status epilepticus
- Appropriate disposition theatre for reduction and fixation the ICU