Medical Law & Ethics in Emergency Medicine + Psychiatry

Question 1

Examples of instances where confidentiality may be breached include:

Answer 1

1.LEGAL OBLIGATION
Cases where there is a legal obligation e.g. informing the HPA of a notifiable disease

2. LEGAL REQUEST
   Legal cases where there is a request for information from a judge
3. RISK TO PUBLIC
   Cases where there is risk to the public e.g. potential terrorism or serious criminal activity
4. RISK TO OTHERS
   Cases where there is risk to others e.g. when a patient has expressed homicidal intent towards a specific
5. RELEVANT TO STATUTORY BODIES
   Cases relevant to statutory regulatory bodies e.g. informing the DVLA of a patient that continues to drive despite a restriction

Question 2

As per NHS improvement revised list of NEVER EVENTS published January 2018 - can you name those events relevant to the Emergency department?

Answer 2

1. surgery:
   wrong site surgery
2. Surgery:
   retained foreign objects post procedure ( eg -swabs, needles, guidewires after Central access )
3. Medication:
   Mis- selection of a strong potassium solution
4. Medication:
   Administration of medication by the wrong route
5. Medication:
   overdose of insulin due to abreviations
6. Medication:
   mis-selection of high strength midazolam for concious sedation
7. Medication:
   Transfusion of ABO incompatable blood products
8. Medication:
   Unintentional connection of a patient requiring oxygen to an airflow metre
9. Mental health:
   Failure to install functional collapsable curtain rails
10. Mental health:
    Chest/neck entrapment in bed rails
11. Mental Health:
    Falls from poorly restricted windows
12. scalding of patients
13. Surgery
    Misplaced oro/naso gastric tubes

Memory aid:
Think :

1 scald, 1 tube, 2 surgical, 3 mental health and 6 medication related,

Question 3

What are:

A. Body packers
B. Body stuffers
C. Body Pushers
D. Paraschuting

Answer 3

Body Packers = planned ingestion of well packaged large volumes of illicit drugs with the intent to smuggle across boarders or into prisons

Body stuffers = unplanned ingestion of poorly packaged drugs in small volumes in an attempt to avoid detection by police

Body Pushers = are stuffers that push it up the vagina, or rectum

Paraschuting = intentional ingestion of drugs wrapped in a covering that is intended to dissolve to release the drug for later absorption

Question 4

Police have brought a patient to the ED suspected of body packing and have requested that you perform a PR exam and an AXR. how do you respond?

Answer 4

PR examination and AXR can only be conducted if you have both the patients consent in writing and it must be authorised from an inspector or similar ranking. also intimate examination should only be carried out by an forensic ME.

Question 5

Your ED has exit block.

Give 2 measures you could take to try relieve some of the congestion in your department.

Answer 5

1. Identifying patients waiting in cubicles who could sit out in seated areas e.g. well patients awaiting blood test or scan results.
2. Identify patients waiting to be seen who could be referred direct to specialties from triage.
3. Identify patients waiting to be seen who could be redirected to a Primary Care service.
4. Board round with your nurse in charge. Identify patients who may be suitable for discharge or whom could be managed in a different area of your department.
5. Discuss patient management plans with your junior staff. Ascertain if the patient they have just admitted be redirected to an ambulatory service
6. Speak to bed management. Find out which patients have been allocated beds and when these beds are available.
7. Escalate to your head of service and patient flow teams that the department is overcrowded and additional measures need to be implemented to generate capacity.

“Maintaining safety in a crowded emergency department – Guide for shift leaders” is an excellent guide for clinicians in charge of the department when it becomes crowded

Question 6

What general safe-guarding measures could you introduce in your department to try and prevent SUI happening again?

Answer 6

1. Patient

Liase with anticoagulation clinic. Ask them to make sure they give written councilling advice when initiating anticoagulants that if the patient suffers a head injury when taking this medication they should present to an Emergency Department

2. Governance

Present case at local Morbidity and Mortality Meeting

Perform an Audit on performance in this area

3. Departmental

Place alerts in department triggering an immediate assessment by doctor for these types of patients

Have an Emergency Department Proforma for patients presenting with head injury on anticoagulants

Develop a policy that initiates a CT request for anyone who presents to triage with a head injury on anticoagulants according to NICE guidance.This may a joint QIP with your local radiology department

4. Teaching

Departmental teaching of junior staff

Introduce this into your induction pack

5. Staff Communication

Send memo to clinical staff reminding about guidance on management of head injuries on anticoagulants

Include this case in your ED monthly newsletter

6. Individual Doctor

Speak to doctor involved and provide appropriate support and training

Question 7

When asking for consent to perform a procedure - what is material risk?

Answer 7

A material risk is any risk to which a reasonable person in the patient’s position would attach significance.

Question 8

According to the RCEM guidance what are the indications for urgent surgical removal of suspected drug packages?

Answer 8

1. bowel obstruction or ileus

2. cocaine or amphetamine toxicity

Question 9

What 2 features particularly distinguish never events?

Answer 9

1. it is a serious incidents that are:

2. Wholly preventable by barriers implemented by all healthcare providers

Question 10

Which process is followed to investigate Never Events?

Answer 10

SIF ( Serious incident framework )

Question 11

Under which circumstances are Deaths reported to a coroner?

Answer 11

1. death was sudden and unexplained
2. death was violent and unnatural
3. cause of death is unknown
4. person was not visited by medical practitioner during final illness
5. death occurred during an operation or before the person came out of anaesthetic

Question 12

After the coroner has performed a post-mortem under which circumstances would you hold an inquest?

( an inquest is a formal investigation conducted by the coroner to find out how someone died )

Answer 12

1. if the cause of death is still unknown,

or if the person:

2. possibly died a violent or unnatural death or
3. died in prison or police custody

Question 13

using the AUDIT-C screening tool - what 3 questions will you ask the screen for problem drinking?

Answer 13

1. how often - do you have a drink containing alcohol?
2. how many - units do you drink on a typical day when you are drinking?
3. How often- have you had more ( 6units female, 8 units male ) on a single occasion in the passed year?

Question 14

What are the physiological effects of a prolonged struggle that would compound the physiological effects of stimulant drugs and result in serious complications?

Answer 14

1. hyperpyrexia
2. dehydration
3. acidosis
4. hypoglycaemia
5. exhaustion

Question 15

A child involved in RTC is unconcious and requires emergency blood transfusion but the parents are practicing jehovas witness- what would you do?

Answer 15

in emergency situations you can administer a blood transfusion to a child jehovas witness under common law - best interest.

If an adult is unconcious in a trauma and requires emergency blood transfusion and next of kin advise that they would not permit a blood transfusion - you would ask the next of kin if there is a witnessd and signed advanced directive.

Question 16

A jehovas witness patient requires an emergency blood transfusion but asks you if there are any other options? what would you advise?

Answer 16

intra-operative red cell salvage

Question 17

A police officer has foned the ED requesting information about a patient in relation to a case. The nurse took the call but did not get his name or rank and he said he would fone back. What would you advise the nurse?

Answer 17

In general if the police do call requesting this type of information you should ask the following details:

i) Name and rank and ID number.
ii) Police contact details.
iii) You should then advise the officer you will call-back.
iv) You should then attempt to confirm the officer’s details via the police main switchboard.

Also Advise them to consider asking:

I) How serious is the crime under investigation?

II) How will the release of this data assist the detection of crime?

III) How will the police be hindered if this data is not provided?

IV) Who within the police has this request for information been discussed with?

V) Given the confidential nature of the information has an application for a Court Order been considered and if it has why has an application not been made?

Question 18

In group 1 and group 2 vehicle drivers what are the DVLA restrictions in the following conditions:

1. reflex vasovagal syncopy ( except cough syncopy )
2. loss of conciousness in low risk patients
3. loss of conciousness in high risk patient group
4. loss of conciousness with seizure markers
5. 1st unprovoked seizure
6. cough syncopy
7. cerebrovascular - TIA’s

Answer 18

1. reflex vasovagal syncopy ( except cough syncopy )
   group 1: no restriction
   group 2: no restriction
2. loss of conciousness/syncopy in low risk patients
   group 1: no restriction
   group 2: 3 months
3. loss of conciousness in high risk patient group
   group 1: 6 months
   group 2: 1 year
4. loss of conciousness with seizure markers
   group 1: 6 months
   group 2: 5 years
5. 1st unprovoked seizure
   group 1: 6 months
   group 2: 5 years
6. cough syncopy
   group 1: 6 months
   group 2: 5 years
7. cerebrovascular - TIA’s
   group 1: 1 months ( if multiple - 3 months )
   group 2: 1 year

Question 19

What are the 7 caldicott principles?

Answer 19

The Caldicott Principles are:

1. Justify the purpose of using confidential information
2. Only use it when absolutely necessary
3. Use the minimum that is required
4. Access should be on a strict need-to-know basis
5. Everyone must understand his or her responsibilities
6. Understand and comply with the law
7. The duty to share information can be as important as the duty to protect patient confidentiality

Memory aid: Eating cake.

Justify eating the whole cake, do it only when it is absolutely necessary, try eat as little/minimum as possible, dont tell everyone - just a need to know basis. Understand your responsibility and comply with the rules.

Question 20

What does a FOI apply to?

Answer 20

The Act only applies to information that already exists in a recorded form.

A member of the public can write to the Trust asking it to disclose information.

The request needs to be in writing (including fax or email)

The person doesn’t need to mention the Freedom of Information Act

The Trust must respond to the request within 20 working days

Question 21

Under what legal obligation is it your duty to respect your patients’ confidentiality.

Answer 21

Under the Common Law Duty of Confidentiality.

A requirement to maintain confidentiality will be set out in your professional code of conduct.

As an employee of the NHS you will have confidentiality requirements included in your employment contract.

Misuse of Personal Confidential data is Gross Misconduct and will be treated with the upmost severity.

Question 22

who has Parental Responsibility?

Answer 22

’# A mother automatically has Parental Responsibilty for her child from birth

#A father usually has Parental Responsibility if he's 
   either:

1. Married to the child’s mother
2. Listed on the birth certificate (after a certain date,
   depending on which part of the UK the child was born
   in)
3. You can apply for Parental Responsibility if you dont
   automatically have it.

#Regarding Birth’s registered in England and Wales:

1. If the parents of a child are married when the child is born, or if they’ve jointly adopted a child, both have Parental Responsibility.
2. They both keep Parental Responsibility if they later divorce

Regarding Unmarried parents:

An unmarried father can get parental responsibility for his child in 1 of 3 ways

1. Jointly registering the birth of the child with the mother (from 1st December 2003)
2. Getting a Parental Responsibility agreement with the mother
3. Getting a Parental Responsibility order from a court.

Question 23

A patient that takes an overdose and presented to the ED. then leaves the department before having a clinical assessment. When should the police be contacted to FORCIBLY bring the patient back to the ED?

Answer 23

All 5 the following criteria must be met:

1. substantial risk to the patient ( if they are not brought back for treatment )
2. the risk requires urgent action
3. all other efforts to contact the patient have failed
4. no other persons can fascilitate the return of the patient ( i.e. gp/nok)
5. both senior nurse and doctor on duty agree it is necessary

Question 24

What measures would you take to prevent a patient who is at risk of absconding - from doing this?

Answer 24

1. place patient in a location that fascilitates observation
2. prioritise patient for assessment
3. allocate member of staff to observe patient and try to
   engage
4. carry out a capacity assessment
5. if a patient wishes to leave- establish what the reason/ concern is and try to address it

Question 25

List the criteria set out by the Fraser guidelines that must be satisfied in order to give contraceptive advice to a teenage girl ( under age 16 ) demanding emergency contraception?

https: //www.nspcc.org.uk/preventing-abuse/child-protection-system/legal-definition-child-rights-law/gillick-competency-fraser-guidelines/
http: //www.cqc.org.uk/content/nigels-surgery-8-gillick-competency-and-fraser-guidelines

Answer 25

1. that the girl ( although under the age of 16 ) will UNDERSTANDS the advice;
2. that the doctor CANNOT PERSUADE her to tell her parents that she is seeking contraceptive advice;
3. that she is LIKELY TO CONTINUE having sexual intercourse with or without contraceptive treatment;
4. that her physical or mental HEALTH WILL SUFFER unless he/she received the advice or treatment;
5. that the contraceptive advice or treatment is in the young person’s BEST INTEREST, even without parental consent

Question 26

What medical advice would you give after prescribing the morning after pill to a patient that has had an UPSI?

Answer 26

1. If she VOMITS within 2 hours, she will need a new tablet.
2. There is a FAILURE RATE up to 5% if taken within 24 hours so needs to check pregnancy test.
3. Look out for lower abdominal pains- small chance of ECTOPIC PREGNANCY RISK.
4. GUM clinic for STI
5. See GP for contraceptive advice

Question 27

A 22 year old comes in with retained condom; you are considering a speculum examination. As per the GMC guidance list any 2 of the principles on performing intimate examination.

Reference: http://www.gmc-uk.org/static/documents/content
/Maintaining_boundaries_Intimate_examinations_and_chaperones.pdf

Answer 27

1. Assess CAPACITY to consent if dealing with a child or young adult
2. Gain informed CONSENT –Explain what the examination will involve in a way that patient can understand
3. Explain why the procedure is necessary and give patient opportunity to ask questions.
4. wherever possible offer the patient to have a CHAPERONE present
5. Maintain patient dignity – privacy to dress and undress

Memory aid:
3 C’s - capacity, consent, chaperone,

Question 28

What does the acronym METHANE stand for?

Answer 28

M-Major Incident declared

E- Exact location

T- Type of incident

H- hazards present or potential Hazards

A- Access to scene

N- Number and severity of causalities.

E- Emergency services Police fire and ambulance

Question 29

Major incident is declared and a call out has been done. What would be one of the first immediate tasks? (1)

Answer 29

1. Clear the Department of current patients.
2. Minors-diverted or asked to leave.
3. Urgent plans for immediate transfer of Majors and
   resuscitation patients to Inpatient specialities.

Question 30

What qualities or criteria would you expect a suitable chaperone to have?

Answer 30

• the chaperone does not have to be medical,
• but they ideally should:

1. be sensitive and RESPECTFUL of the patients dignity confidentiality
2. be FAMILIAR with the procedure involved in a routine intimate examination
3. be prepared to REASURE the patient if they show discomfort or distress
4. be prepared to RAISE CONCERNS about a doctor if misconduct occurs

Question 31

Give an example, as stated by the GMC guidelines, where doctors’ use of social media can benefit patient care?

as per GMC guidelines on use of social media

Answer 31

1. engaging people in PUBLIC HEALTH policy discussions
2. establishing PROFESSIONAL NETWORKS ( nationally &internationally )
3. Fascilitating PATIENTS ACCESS TO INFORMATION about health and services

Memory aid:
PEOPLE IN PUBLIC HEALTH-
PROFESSIONAL NETWORKS -
PATIENTS ACCESS TO INFORMATION

Question 32

Give 4 factors that are associated with fatality during restraint?

Answer 32

1. mechanical restraints
2. neck holds
3. obstruction of nose/mouth
4. hobble tying
5. prone tying
6. obesity / heart disease
7. unsupervised sedation
8. exhaustion

MEMORY AID:
neck hold and mechanically restrain an obese man, tie him prone, obstruct his mouth and nose untill he is exhausted or carry out unsupervised sedation

Question 33

What key issue should be explored before the use of restraint is employed?

Answer 33

1. Ensure that ALL OTHER OPTIONS have been fully explored and restraint is the only option left to protect the patient themselves or others from the patients’ violent behaviour
2. AVOID DANGEROUS restraint techniques
3. use restraint for the MINIMUM TIME possible with the LEAST AMOUNT OF FORCE

Question 34

An 88 year old handed over any decisions about her health to her son before she became ill. she had capacity at that time but now has been diagnosed with dementia.

1. WHat is the name of the position that her son now has in reference to her health?
2. with whom does this have to be registered to be valid?

Answer 34

1. he has Lasting Power of Attorney

there are 2 types of LPA :
a personal health and welfare LPA and
a Property and financial Affairs LPA

2. it must be registered with th office of the public guardian

” LPA registered with OPG “

Question 35

As per the new statement of Fitness to Work:

1. In the 1st 6 months of an illness - what is the maximum period of time a patient can be declared not fit to work?
2. which form is used as evidence of a period in hospital as an in-patient?

Answer 35

1. no longer than 3 months

2. Form Med 10

Question 36

According to the Ministry of Justice on the completion of Cremation forms:

1. which 2 criteria must be fulfilled for a doctor to complete form Cremation 4?
2. can the same doctor complete the form Cremation5 after completing Cremation 4 ?

Answer 36

1. criteria that must be fulfilled:
   * be a fully registered medical practitioner
   * the practitioner must have a licence to practice with
   the GMC
2. No

Regulation 17 of the Cremation guidelines states that the following doctors should not complete form Cremation5:

• relatives of the deceased
• colleague working in the same hospital team as the doctor that completed form Cremation 4
• colleague working in the same GP practice as the doctor that completed form Cremation 4

Question 37

A 50 year old with metastatic prostate cancer previously decided he would not want IV antibiotic therapy to treat an infection if he became seriously ill. he was concerned that he might be too unwell to communicate his decision in these circumstances, and he made a statement regarding his wishes.

1. what is the name of this statement?
2. what 2 important factors need to be in place for this staement to be upheld?

Answer 37

1. An Advance Decision to Refuse Treatment
2. th ADRT must be both VALID and APPLICABLE to the current medical situation

*VALIDITY means:
the person has not withdrawn their decision, or subsequently made a LPA in health and welfare

• APPLICABLE means:
  it must be applicable to the treatment in question

Question 38

What 3 specific requirements must an ADRT fulfill?

Answer 38

1. It must be in writing
2. It must be signed by the maker in the presence of a witness who must also sign the document
3. It must be verified by a specific statemnt made my the maker, that says the advance decision is to apply to the specified treatment EVEN IF LIFE IS AT RISK

Question 39

What are the 4 domains that make up the framework of the GMC’s Good Medical Practice?

Answer 39

1. KSP ( knowledge, skills, performance )
2. Q&S ( quality and safety )
3. communication, partnership & teamwork
4. Maintaining Trust

MEMORY AID:

” KSP and Q&;S, must keep the Trust and communicate with the team “

Question 40

What is the role of the Caldicott Guardian?

Answer 40

The Role of the Caldicott Guardian is to:

ensure that the NHS ( & its partner organisations )
satisfy the highest practical standards
for handling and protecting
patient identifiable information

” ENSURE THE NHS - SATISFIES HIGHEST STANDARDS
FOR HANDLING P.I.I “

Question 41

Give 3 types of situations that you must inform the GMC about yourself no matter where you are in the world!?

Answer 41

1. if you have accepted a CAUTION from the police or been critisized by an official enquiry
2. if you have been CHARGED or found guilty of a criminal offence
3. if another professional body has made a finding against your registration as a result of FITNESS TO PRACTICE PROCEDURES

CAUTION from the police…..
……………CHARGED of criminal offence…..
………………………………FITNESS 2 PRACTICE PROCEDURES

Question 42

What is an advanced directive?

Answer 42

an advanced directive is a :

• legally binding document
• allows the conveyance of decisions
• regarding EOL (end of life) care
• ahead of time

Question 43

Give 4 examples of the use of advanced directives?

Answer 43

1. to make decisions regarding CPR
2. to make decisions about the use of IV fluids &
   parenteral nutrition
3. to make decisions about specific procedures
4. to make decisions about the use of blood products
   for Jehovas witnesses

Memory aid:
CPR, IVF + TPN, Jehovas blood, procedures

Question 44

Give cardiovascular conditions that are contra-indications to commercial flight by the Civil Aviation Authority

https://www.caa.co.uk/Passengers/Before-you-fly/Am-I-fit-to-fly/Guidance-for-health-professionals/Assessing-fitness-to-fly/

Answer 44

1. uncontrolled hypertension
2. uncontrolled cardiac arrythmia
3. unstable angina
4. uncomplicated MI within 7 days
5. complicated MI within 4-6 weeks
6. CABG within 10 days
7. decompensated CCF
8. severe symptomatic valvular heart disease
9. CVA within 3 days

Question 45

What 3 criteria must be fulfilled in order for the taking of consent to be delegated to another clinician whom is NOT performing the actual procedure?

Answer 45

The clinician delegated to must:

1. have undertaken suitable training
2. must have suitable knowledge of the procedure
3. must understand the risks and benefits of the procedure

memory aid:
training, knowledge, risks and benefits

Question 46

If you are considering breeching patient confidentiality without a patients permission which two bodies should you seek advice from?

Answer 46

1. Trust legal advisor

2. Your Medical defence Union

Question 47

You are treating a man for injuries that he says were caused by his wife a few days ago. He asks you not to tell anybody.

1. what should you asertain before making any further decision regarding the information?
2. The patient has capacity - what options can you offer him?

Answer 47

1. assess wether he has the capacity to make the decision.
   if he does not have capacity - then you should make a decision based on his best interest, which may involve raising a safeguarding concern

• decide if he is in immediate danger - in which case contact the police
• enquire about any children that live with him and his wife and ask if they could be at risk of harm - in which case raise a child safeguarding concern

2. any one of:
   * offer to contact his GP
   * offer to speak to social service
   * suggest he talks to the NDVH
   (national domestic violence helpline)

Question 48

Give examples where a doctor would NOT be legally obliged to follow an advanced directive?

Answer 48

1. changes have been made which invalidate the directive
2. there have been changes in treatment which alter circumstances
3. there is ambiguity in the wording of the directive
4. it is unsigend ( or authenticity is in doubt )

Question 49

Give 5 examples of services that are free at point of use to overseas visitors.

Answer 49

1. A&E services
2. Family planning services ( except TOP’s - termination of pregnancy )
3. diagnosis &treatment of specified Infectious diseases
4. diagnosis & treatment of sexually transmitted infections
5. treatment required for a physical or mental condition caused by FGM, torture, sexual violence, domestic violence )

Question 50

Drivers with insulin-treated diabetes mellitus must satisfy a specific criteria in order to drive.

what are the 5 criteria?

Answer 50

1. they must have AWARENESS of hypoglycaemia
2. they must NOT have had more than 1 episode of hypoglycaemia requiring the assistance of another person in the preceeding 12 months
3. must monitor blood glucose no more than 2 hours before the start of the first journey
4. must monitor blood glucose levels every 2 hours whilst driving
5. visual standards for acuity and fields must be met

Question 51

What is a schedule 2 drug? and give examples

Answer 51

Schedule 2 Drugs:

These are drugs that are subject to the full drug requirements
relating to :
*prescriptions 
*safe custody 
*and the need to keep registers

EXAMPLES of schedule 2 drugs:
cocaine, diamorphine, pethidine, methadone, methylphenidate, fentanyl

Question 52

regarding schedule 2 drugs:

1. how should the prescription be written out?
2. how should these drugs be stored?

Answer 52

1. prescription must show the FORM and STRENGTH of the preparation, total quantity must be written out in both WORDS and NUMBERS
2. store them in fixed double-locked safety cabinets and maintain a written register.

Question 53

How does the requirements for schedule 3 drugs differ to schedule 2?

Answer 53

Schedule 3 drugs are a small number of stimulant drugs less likely to be misused than schedule 2. e.g. midazolam, temazepam, barbiturates, buprenorphine.

Regarding the prescription, safe custody and keeping a register:

• subject to the same prescription requirement
• exempt from safe custody requirements
• no legal requirements to keep registers

Question 54

What is the definition of antimicrobial stewardship?

Answer 54

ANTIMICROBIAL STEWARDSHIP:

is a set of coordinated interventions that aim to improve the use of antimicrobials with the goal of

1. improving patient health outcomes
2. reducing antibiotic resistance
3. decreasing unnecessary cost

Question 55

What is a Significant Event Analysis? ( SEA )

Answer 55

• a qualitative method of clinical audit,
• concerned with structured investigation of individual events
• identified by a member of the heatlh care team, and deemed to be significant

Question 56

GIve 3 examples, according to the GMC guidelines, when it is acceptable to prescribe for yourself OR for someone with whom you have a close personal relationship.

Answer 56

1 - if there is no other person available with the legal right to prescribe AND a delay in getting a prescription would put your or the patient’s life or health at risk

2 - if the treatment is - immediately necessary to save a life

3 - if the treatment is - immediately necesary to avoid serious deterioration in health

4 - if the treatment is - immediately necessary to alleviate otherwise uncontrollable pain or distress

memory aid:
#no other person who can prescribe AND delay = life at
risk
#its immediately necessary to save a life or
#its immediately necessary to avoid serious
deterioration

Question 57

According to the Civil Aviation Authority - what is the minimum haemoglobin concentration with which a person can fly without consideration?

https://www.caa.co.uk/Passengers/Before-you-fly/Am-I-fit-to-fly/Guidance-for-health-professionals/Haematological-disorders/

Answer 57

HB 7.5g/dL

If the haemoglobin is less than 7.5 g/dl, special assessment should be made and the use of supplemental oxygen should be considered.

Patients with a haemoglobin of greater than 8 g/dl may travel without problems assuming there is no coexisting condition such as cardiovascular or respiratory disease.

Question 58

What are the cardiovascular indications ( other than anaemia ) for the use of supplemental oxygen during commercial airline flights?

www.caa.co.uk/fitness-to-fly

Answer 58

• already using oxygen at baseline altitude
• cyanotic congenital heart disease
• primary pulmonary hypertension
• CCF ( NYHA class 3/4 )

Question 59

a 25 year old man with severe learning disability has never had capacity to make decisions about his care. his parents are divorced and frequently disagree about the type of medical care he should receive. HIs sister recently applied to the Court of protection to become the one that makes decisions about her brother’s care.

1. what is the role she would have applied for?
2. what are the circumstances that might have lead to the court appointing her this role

Answer 59

1. to become her brothers personal welfare deputy
2. the fact that there have been disagreements by the parents regarding the sons medical care

NOTE: a personal welfare deputy is appointed by the Court of Protection to make decisions about medical treatment and care for an adult who lacks capacity ( and is expected not to regain capacity ).
the court will appoint a deputy to make decisionover time ( for example about place of care ) or if there is doubt about decisions being made in a persons best interests ( eg. family disagreements ).

Deputies are usually relatives or close friends and more than 1 may be appointed.

Question 60

a 79 year old with dementia lives in a nursing home, he has no relatives, friends, attorney or deputy. He does not have capacity to consent for treatment. his has severe shortness of breath and may need ITU.

1. Who should be appointed to make decisions about his medical care?

Answer 60

1. an independent mental capacity advocate

( IMCA )

an IMCA would not be appointed if the person had an attorney or a deputy.

Question 61

Which 3 circumstances will an IMCA be involved in a patients care?

Answer 61

An IMCA will only be involved if:

1. the decision is about SERIOUS MEDICAL TREATMENT provided by the NHS
2. it is proposed that the person be moved into long-term care of more than 28 days in a hospital ( or 8 weeks in a care home )
3. A long-term move ( 8 weeks or more ) to different accomadation is being considered, eg. to a different hospital or care home.

Question 62

A 4 year old dies in the department. Lab tests confirm he had meningococcal septicaemia.

1. to which authority must a report be made?
2. who else should be informed about this case?

Answer 62

1. The Consultant in Communicable Disease Control within 72 hours ( if the case is urgent then within 24 hours ).
   Medical practitioners have a “ statutory duty to notify a proper officer of the Local Authority of suspected cases of certain infectious disease”.
2. The Coroner

Question 63

The Law gives a checklist of key factors which you must consider when working out what is in the best interest of a person who lacks capacity.

Can you name a few points from this checklist?

Answer 63

1. It is important not to make an assumption about someones best interest based on their age or appearance
2. the decision-maker must consider all the relevant circumstances relating to the decision
3. the decision -maker must consider wether the person is likely to regain capacity - if so, then can the decision wait untill then?
4. the decision maker must involve the person as fully as possible in the decision that is being made on their behalf
5. if the decision concerns the provision or withdrawal of life-sustaining treatment, the decision-maker must not be motivated by a desire to bring about the persons death

Question 64

In a case where the doctor is taking the decision in patients best interest-

which specific people must be consulted if it is appropriate to do so and take into account their views as to what would be in the best interests of the person lacking capacity?

Answer 64

1. anyone previously named by the person lacking capacity as someone to be consulted
2. carers,close relatives, ot close friends interested in the persons welfare
3. any attorney appointed under a LPA for health
4. Court appointed Deputy

Question 65

1. Up to what gestational age do most airlines allow travel for a single pregnancy?
2. from what gestational age do most airlines require a fitness to fly certificate?
3. what information should the fitness to fly certificate contain?

Answer 65

1. 36 weeks for a singleton, 32 weeks for multiple pregnancies
2. for pregnancies over 28 weeks
3. fitness to fly certificate should contain:

• confirmation that the pregnancy is progressing
  normally
• confirmation that there are no complications
• expected date of delivery

Question 66

Under the MHA -

What is the difference between section 5(4) and 5 (2) ?

Answer 66

Section 5(4) – 
a ‘holding power’ for a nurse (usually senior psychiatric nurse )– to detain someone for up to 6hrs: either for consideration by a DR of whether to use their 5(2) holding power; or to arrange an MHA assessment. 

Again, this holding power can only be used on patients already admitted.

Section 5(2) – a ‘holding power’ for DRs to detain an inpatient in hospital for up to 72hrs for assessment under the Act. Cannot be used in A&E because the patients there are not (yet) “inpatients”.

Can be used by non-psychiatric doctors on inpatients with psychiatric problems who are on ‘general’ medical wards in a non-psychiatric hospital.

Question 67

Under the MHA - what is section 2 and section 3?

Answer 67

Section 2 – the power to detain someone believed to be suffering mental disorder for assessment (and treatment). The order lasts for up to 28 days and cannot be extended or renewed. It is imposed after application by an AMHP and two DRs one of whom must be “section 12 approved”.

Section 3 – the power to detain someone for treatment of mental disorder. This order lasts for six months and can be renewed. It is imposed after application by an AMHP and two DRs one of whom must be “section 12 approved”.

Section 4 – the emergency power to detain someone for assessment for up to 72hrs. This is in effect a s2 detention, but is imposed where an AMHP and only one s12 Doctor believe it is needed and delay for a 2nd doctor is impracticable. No right of appeal.

Question 68

What is confirmation bias?

RCEM Learning SAQ

Answer 68

When we become fixated on one diagnosis, there is a risk that we look exclusively for evidence to support that diagnosis, ignoring evidence to the contrary, or manipulating it to meet the perceived diagnosis. This is termed confirmation bias.

Question 69

List 4 items in the CIWA ( clinical institute withdrawal assessment for alcohol ) scale

Answer 69

1. tactile disturbance
2. visual disturbance
3. auditary disturbances
4. anxiety
5. agitation
6. tremor
7. sweating ( paroxysms )
8. nausea/vomiting
9. headache
   10 orientation

Memory AId:
Lose 3 of your senses ( touch, sight, sound ) and feel anxious, agitated, start to tremble and sweat

*max score is 67
*mild alcohol withdrawa - <5
Moderate alcohol withdrawa 6-20
severe alcohol withdrawa >20

Question 70

What is Kurt -Schneider’s 1st rank symptoms of schizophrenia?

Resource: FRCEM exam prep SAQ’s

Answer 70

PAD

1. Passivity phenomena -
   thought insertion
   thought withdrawal
   thought broadcast
2. auditory hallucinations
   thought echo
3. Delusions:

Question 71

a patient with bi-polar mood disorder- what features are consistent with a diagnosis of mania?

Answer 71

1. increased appetite
2. increased libido
3. increased sexual promiscuity
4. increased energy
5. increased risk taking

Question 72

List 5 extrapyramidal side effects in a patient taking medication for schizophrenia?

Answer 72

1. Tremor
2. Tardive dyskinesia
3. Akathisia
4. Dystonias
5. Rigidity

Memory aid:
TTADR

Question 73

1. What is neuroleptic malignant syndrome ?
2. what clinical features would you look for?
3. which drugs could cause NMS?
   https: //www.pharmaceutical-journal.com/learning/learning-article/which-medicines-can-cause-neuroleptic-malignant-syndrome/11102025.article?firstPass=false

Answer 73

1. NMS is a rare life threatening, idiosyncratic drug reaction to neuroleptic medications
2. characterised by:
   * hyperthermia >38.5 C
   * muscle rigidity ( trismus )
   * altered mental state ( delirium, drowsy )
   * autonomic dysfunction( HR, BP, incontinence )
3. drugs that cause it:
   * Haloperidol
   * chlopromazine
   * fluphenazine

NMS is characterised by four groups of symptoms:

Hyperthermia — body temperature over 38.5C;

Autonomic instability — eg, tachycardia, fluctuating blood pressure, diaphoresis, incontinence;

Altered consciousness — eg, drowsiness, stupor, confusion, delirium, coma, tonic-clonic seizures;

Muscle rigidity — eg, trismus (jaw contraction),
extrapyramidal symptoms, rhabdomyolysis.

Laboratory findings include elevated creatinine kinase, leukocytosis and deranged liver function tests;