Misc OSCE

Question 1

Question 2

Approach to Impaired Colleague:

Answer 2

• Upfront, state reason for meeting
  –> “I noticed that….. the nurse in charge observed….”
  –> “This is out of character. Is there anything else going on?”
  –> “I wanted to see if I can help”
• Explore reasons/ stressors
• Explicit SUICIDE/SAFETY CHECK
• Explore supports + offer additional
  –> “The department will be able to support you with sick leave. There is a doctor’s support line on….”
• MANDATORY REPORTING… can encourage to self-report.
• Immediate actions
  –> “We will have to take you off the floor today”, sick leave
• Statement of support, privacy + arrange follow up

Question 3

ELDERLY considerations

Answer 3

PECULIARITIES:
Frailty, falls risk
Atypical and subtle presentations
Impaired communication of symptoms
Clinical tools don’t always account for elderly
Complex, interacting comorbidities
Polypharmacy
Cognitive: ability to understand/comply with treatment plans/ safety net
May have substitute decision makers, other carers to involve in decisions
Advance care directives and appropriate GOC
Elder abuse
Delirium mitigation
Alternative discharge destinations

ENVIRONMENT
- Orientation boards + clocks
- Well signed
- Lighting for navigation
- Noise reduction
- Grip surfaces
- Falls: clutter free, low bed, aides, bed alarms
- Quiet location for EOL care
- Accessibility
- Modified foods and fluids
- Pressure mattresses

NON-CLINICAL
- Audits, KPIs re elderly
- MultiD aged care team
- Policies with geriatrician and stakeholder input

Question 4

Safety and QI:

Answer 4

Policy and procedure
ED design
Performance indicators
Governance
Education & training

Question 5

Radiation/ Imaging counselling:

Answer 5

Like all tests, don’t do unless we feel benefit outweighs risk. Risk of missing X, greater than the risk of cancer from doing Y image.

Also, take all measures possible to limit radiation exposure during scan

Risk greater to kids and women, and less to men and elderly.

My practice is to calculate individual risk on XrayRisk.com calculator
_______________________

1 CXR = 10 days background radiation = 1: 1 million cancer risk.

CTs are more radiation.
Depending on type, 1:1-2000 risk of cancer.
–> More risk of dying in fire, or from appendicitis
–> WAY LESS than natural cancer risk (1:5)

Avoid if not necessary, but represent very fractional increase in cancer risk.

Question 6

PROCEDURE template:

Answer 6

Indications
Contraindications
- Patient
- Incl. competing departmental pressures, better alternative
Informed consent
Set up
- Space
”full monitoring and resus capacity”
- Personnel
- Drugs
- Equipment
Including for complications
Procedure
Positioning
”Sterile scrub, glove, (gown), prep, drape”
Aftercare
Incl. check for effect and complications