Procedures & Airway Management OSCEs

Introduction. Performing at least one, if not more, practical procedures is an absolute certainty in the MRCEM PART C/OSCE exam. It is also reasonable to assume that you would have performed most of the required procedures numerous times before at work, and performed them to a high standard. Sadly numerous candidates fail what could otherwise be a relatively straight forward station, often due to cutting corners on the actual procedure, poor communication with the patient or not securing key generic marks. The task. Many procedures can take longer than the allotted seven minutes, thus in the OSCE you may be asked to do one of the following things:

• to perform the whole task for very short procedures, • perform just a particular part of the procedure (eg insert the central line but not suture it in etc.) • To explain and talk through a procedure to a junior doctor or medical student

Communications. Often ignored, procedure stations have a significant element of communication and it is here that the candidates often loses essential marks. As with all stations, it is important to assume the role fully, and just because there is a part section of a manikin or plastic model in front of you, it is vital to interact, communicate and talk out aloud as you would to a real patient. Increasingly there may be an actor present, to whom you initially tall to take the history and obtain consent, and then move onto the model – be sure to keep communicating and interacting with the actor even when working on the model as silence will be picked up by the examiner and actor and will inevitably cost you global marks. Another added complication to the scenario may be the presence of an anxious/interfering/obstructive relative that wants to remain with the patient throughout the procedure. Allow them to remain, explain everything to them as you go along and reassure them at every stage with continual calmness and empathy, just as you would do to any real patient in your department. The Procedure OSCE. The procedure OSCE can be divided into 3 equally important parts:

• Preparation • Procedure • post-procedure care.

Let’s look at each part in turn: Preparation. Efficient but thorough preparation is essential and carries a significant proportion of the marks in procedures stations. Introduce yourself and, of vital importance in this station, check the patient’s identity. All procedures, however, simple should have full verbal consent obtained. Consent should explain the reason for the procedure, the benefits of having it done, and the possible complications. Time must be given for the patient or relatives to ask questions (there will be marks for this), especially if there is a concerned relative present. Say you would record consent in the notes. Next, review and check all relevant notes and investigations to hand, for example, checking the chest X-ray before aspirating the chest is mandatory (in real life as well as OSCEs). Set up your equipment meticulously, on a sterile field if required (it usually is) Stopping mid-procedure to get more materials can only look bad, and so be sure to check and talk through in your mind the procedure so that everything is laid out in order, checked and ready for use. If you have an assistant to help you, it is good practice to check their level of competence and to briefly talk through what you will need them to do. This can show good leadership and team skills and can earn you good global marks. Wash your hands and put on or indicate you would use universal precautions (gloves, gown and eye protection). Sterile procedures must also have meticulous attention paid to a correct and sterile donning of a gown and sterile gloves. In reality, time constraints may mean the examiner will accept you stating that you want to do this but allow you to proceed without for the sake of time. You will still get the mark as long as you made it crystal clear that it was your intention to be fully aseptic. Finally before starting, recheck the patient and in particular check their observations, place them on appropriate monitoring and ensure that there are resuscitation facilities to hand if required. Check the need for and administer analgesia as required. The Procedure. The range of procedures potentially encountered in the MRCEM PartC/OSCE covers a spectrum, from simple daily procedures such as blood gas sampling to the once in a life time needle pericardiocentesis. The basic core skills and competencies set out in the ACCS curriculum must all be considered fair game for assessment. By default before reaching the stage of sitting your OSCE you will have achieved most if not all of your competencies, and thus the OSCE should not present you with anything unfamiliar. The twists may be the relative present, the teaching angle or conducting only a small section of the procedure. Included in this module are a series of procedure videos taking you through the approach and practice of procedures most commonly encountered in the MRCEM OSCE exam. Take time to go through them, make sure you have performed them yourself – either independently or under supervision – and are also able to describe the procedure to a student or junior doctor. There are also many excellent You tube videos of emergency medical procedures but check that they are appropriate for your grade and for the UK approach required. To be clear, though, there are numerous variations on how to perform many of the required MRCEM procedures, (eg the male catheter with the double glove or dirty hand/clean hand technique) and no one technique is necessarily right or wrong. The key remains to proceed in a systematic way, preparing efficiently and conducting the procedure in a methodical, safe and empathic manner. Post-procedure care. This section is equally as important but many candidates, often with an over-emphasis on the procedure itself, run out of time and forget about post procedure management and advice. Many procedures will have specific advice that must be given to the patient or nursing staff caring for them (see the accompanying videos) but there are some generic points to make sure you include in your post-procedure care:

• Procedures that involve sharps the candidate must specifically dispose of the sharps themselves and clarify this to the examiner. As in real life, it is not the job of the assistant to clear away sharps!

• Many procedures will require observations to be performed immediately afterwards to reassess the patient.

• It is courteous and important to explain to the patient the success or failure of the procedure and the steps that need to be taken now (eg check x-ray post aspiration of pneumothorax).

• Give clear and detailed instructions for post-procedure investigation, for example X-rays or samples that must be sent to the laboratory for investigation.

• Give post-procedure instructions to the patient and safety net if they can now go home.

• Indicate that you would document fully the procedure in the notes detailing essentials such as your name, grade and contact bleep or extension. Also take time to document the specifics such as sizes of chest tube, location inserted, number of attempts and any complications.

Summary Though easier said than done, procedure stations should be looked forward to in the OSCE. With a clear understanding of the above approach to procedures stations, they should be minimally challenging and considered safe passes. There is no substitute however for practice, and be sure to take the time to hone your approach and skills both at work and in the simulation lab.