SAQ 1
An 83 year old female is BIBA from her home. She was found on the floor and was awake bit very confused initially when found by her cleaner. During your assessment you realise she has broken her left neck of femur and needs an operation.
- What are the elements of a valid consent? (5 marks)
- Legally capable/competent to give consent, ie able to use and understand info to make a decision
- Freely given
- Informed
- Must be specific
- Must cover what is actually done
- What features do you need to assess to ascertain she has capacity to decide which treatment she wants? (5 marks)
- Communication – can patient communicate their decisions
- Retention – remember long enough to consider it
- Comprehension – understand what is told
- Credibility – do they believe the info and the staff
- Conclusion – can they synthesise the info to reach a logical decision>\?
- Which patient categories are unable to consent? (5 marks)
- Children under 14 (14-16 can if emancipated (only to certain procedures). Implies that parents cannot be provided information
- Intellectually impaired – from guardian or board
- Mentally ill – treat if urgent
- Disabled by intoxication – use implied consent, get second opinion
- Impaired by physical illness – implied consent unless advanced directive
SAQ 2
You are asked by the medical student why a patient has been given a triage category 2. With respect to the Australasian Triage System:
- List the criteria for giving an ATS category 2 to a patient. (3 marks)
- Emergency Ax and Rx <10 mins
- Potential risk to life/organ systems if not seen in timely manner
- Potential for time critical treatment that would significantly affect outcome depends on treatment commencing within a few minutes of the patients arrival in ED.
- List examples of symptoms or possible diagnoses which would elicit an ATS category 2 to a patient. (3 marks)
- Chest pain of probable cardiac origin
- GCS <13
- Fever with lethargy
- Significant toxic ingestion or exposure
- Which features in a mental health presentation would result in giving an ATS category 1 to a patient? (3 marks)
- Severe behavioural disturbance with immediate threat of violence/extreme agitation
- Possession of weapons
- Self-destruction in ED
SAQ 3
You have been asked by the ED director to write a business case for a new ultrasound machine.
- What are the elements to include in your proposal for the purchase? (7 marks)
- Assess need – for ED and hospital, numbers, new or replacement
- Which model and why – consult other departments, staff, best cost for use
- Compatibility with other equipment/departments
- Funding – annual budget, special funding, maintenance, running cost
- Purchase – and delivery time
- Implementation – physical location, power supply
- Education – staff, ongoing training
- Trial – set time, staff feedback
- Assess benefit – audit, cost-benefit analysis
- Which features would you consider important in choosing the model to purchase? (5 marks)
- Consult other departments
- Functions, size
- Upgrades available?
- Fulfil standards?
- User friendly
- Support – services, spare parts
- Best cost for use
- Compatible with other equipment/departments
SAQ 4
You are the consultant on duty when one of the female nurses approaches you and complains about the registrar who has just left after the night shift.
She was rude and condescending towards the nurse, who has decided to tell you because it has happened on other shifts as well. Furthermore, the nurse has got the impression that other members of the nursing staff feel intimidated by the doctor.
- How would you proceed with respect to the complainant? (4 marks)
- Ask about details, document
- Ask to put into writing
- Assure her it will be investigated and she will be updated
- Ask what they want – apology, police
- Appropriate referral, follow up date, leave required for stress?
- How would you investigate the incident? (3 marks)
- Policies in place? Bullying, harassment.
- Collateral evidence – interview other staff
- Details feasible – was MO at work at the time of incident, etc
- Involve assistants – harassment officer
- How would you approach the meeting with the doctor involved? (2 marks)
- Suggest support person present – eg legal rep
- Non-judgmental/non-threatening approach
- Supportive but firm
SAQ 5
It is Friday evening at handover. It is 2300. A 14 year old girl is BIBA after being found running in and out between cars and was very agitated. On arrival, she is screaming and yelling at the ambulance entry and trying to run back out. Her parents are on their way.
- What are the main issues in this situation? (10 marks)
- Handover – interrupted
- Night time – fewer staff
- Minor – consent, parents
- Injuries sustained?
- Reasons for agitation – mental health vs organic cause
- De-escalation methods
- Issues regarding restraining a child/teenager
- Legal issues regarding restraint
- Safety – patient, staff, other patients
- Confidentiality – get to a separate area
- Pregnancy?
- NAI?
SAQ 6
The mother of a child makes a complaint. She states that three days previously, her 5 year old son had presented to the ED with elbow pain after a FOOSH. Following X-rays, the treating doctor had “pulled on the elbow several times causing him to cry”. The doctor stated that he had suffered a “sprained elbow” and to return if the pain did not settle.
The mother is distressed that her son had received no analgesia for the sprain and that he continued to not move the elbow because of pain. She also complained that the doctor spoke in a rude and insulting manner, and was very rough in his examination.
During your investigation, you find that the official report of the X-ray showed a supracondylar fracture.
- In dealing with the complaint, describe the features of your immediate response. (6 marks)
- Early contact with the complainant
- Immediate review and treatment in ED – if not already managed in another hospital
- Senior staff to handle
- Neutral, empathetic, non-judgemental
- Treat it seriously
- Express regret without liability
- Get complainants side of story – ie MAIN complaint
- Your further approach to the complaint includes? (6 marks)
- Interview staff – recollections, medical defence needed, case not review
- Counsel staff – acknowledge feeling of guilt, counsel regarding errors
- Teaching/training/protocols – may need modification, staff education
- Complaints department – notify, provide documentation
- Feedback to complainant – aim to give definitive reply in 3 days
- Documentation
SAQ 7
Your CEO is reviewing the clinical governance framework of the hospital and asks you to send him the ACEM recommended clinical indicators for ED performance within each of the domains.
- What are the domains? (6 marks)
- Access
- Safety
- Acceptability
- Effectiveness
- Efficiency
- Continuity
- List an indicator for each domain. (6 marks)
- Access – waiting time, access block
- Safety – work related injury, patient falls, body fluid exposures
- Acceptability – patient satisfaction survey ratings, written complaint rate
- Effectiveness – admission rate by triage category, time to thrombolysis, unplanned readmit rate
- Efficiency – waiting time by Australasian Triage Scale
- Continuity – provision of written health information for sentinel conditions (eg asthma, dc summaries)
SAQ 8
Your director asks you to write a protocol for assessment of PV bleeding in early pregnancy. With respect to designing a protocol, write the headlines which need to be included in ANY clinical protocol. (8 marks)
- Rationale for needing a protocol
- Background information (evidence base for protocol)
- Target – inclusions, exclusions
- Recommendations – flow diagram good
- Special considerations – subgroups, eg paeds
- References/evidence base
- Authorising person/body and date
- Review date and history