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General skills

Station 8 Intravenous drug injection 17

After the procedure

• Ensure that the patient is comfortable and ask him to notify a member of the healthcare team

if he notices any adverse effects (it may be necessary to monitor the patient).

• Ask him if he has any questions or concerns.

• Thank him.

• Sign the prescription chart and record the date, time, drug, dose, and injection site of the intravenous injection in the medical records.

• Indicate that you would have your checking colleague countersign it.

Clinical Skills for OSCEs

18 Station 9

Examination of a superficial mass and of lymph

nodes

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• If allowed, take a brief history from him, for example, onset, course, effect on everyday life.

• Explain the examination and obtain consent.

• Consider the need for a chaperone.

• Ask the patient to expose the lump completely; for example, by undoing the top button of his shirt.

• Position him appropriately and ensure that he is comfortable.

The examination (IPPA: Inspection, Palpation, Percussion, Auscultation)

• Inspect the patient from the end of the bed, looking for other lumps and any other signs.

• Inspect the lump and note its site, colour, and any changes to the overlying skin such as

inflammation or tethering. Note also the presence or absence of a punctum.

• Ask the patient if the lump is painful before you palpate it. Is the pain only brought on by palpation or is it a more constant pain?

• Wash and warm your hands.

• Assess the temperature of the lump with the back of your hand.

• Palpate the lump with the pads of your fingers; if possible, from behind the patient. Consider:

– number: solitary or multiple

– size: estimate length, width, and height, or use a ruler or measuring tape

– shape: spherical, ovoid, irregular, other

– edge: well or poorly defined

– surface: smooth or irregular

– consistency: soft, firm, hard, rubbery

– fluctuance: rest two fingers of your left hand on either side of the lump and press on the lump with

the index finger of your right hand: if your left hand fingers are displaced, the lump is fluctuant

– pulsatility: rest a finger of each hand on either side of the lump: if your fingers are displaced,

the lump is pulsatile

– mobility or fixation: consider the mobility of the lump in relation both to the overlying skin

and the underlying muscle

– compressibility and reducibility: press firmly on the lump to see if it disappears; if it immediately

reappears, it is compressible; if it only reappears upon standing or coughing, it is reducible

• Percuss the lump for dullness or resonance.

• Auscultate the lump for bruits or bowel sounds.

• Transilluminate the lump by holding it between the fingers of one hand and shining a pen torch to it

with the other. A bright red glow indicates fluid whereas a dull or absent glow suggests a solid mass.

• Examine the draining lymph nodes (see below), or indicate that you would do so.

After examining the lump

• Ensure that the patient is comfortable.

• Ask him if he has any questions or concerns.

• Thank him.

• Wash your hands.

• Summarise your findings and offer a differential diagnosis.

• If appropriate, suggest further investigations, e.g. fine needle aspirate cytology (FNAc), biopsy,

ultrasound, CT.

General skills

Station 9 Examination of a superficial mass and of lymph nodes 19

Lymph node examination

Head and neck

The patient should be sitting up and examined from behind. With the fingers of both hands, palpate

the submental, submandibular, parotid, and pre- and post-auricular nodes. Next palpate the anterior

and posterior cervical nodes and the occipital nodes.

Submental

Anterior cervical

Submandibular

Parotid

Preauricular

Posterior

auricular

Occipital

Posterior

cervical

Figure 3. Lymph nodes in the head and neck.

Upper body

• Palpate the supraclavicular and infraclavicular nodes on either side of the clavicle.

• Expose the right axilla by lifting and abducting the arm and supporting it at the wrist with

your right hand.

• With your left hand, palpate the following lymph node groups:

– the apical

– the anterior

– the posterior

– the nodes of the medial aspect of the humerus

• Now expose the left axilla by lifting and abducting the left arm and supporting it at the wrist

with your left hand.

• With your right hand, palpate the lymph node groups, as listed above.

Clinical Skills for OSCEs

20 Station 9 Examination of a superficial mass and of lymph nodes

Anterior

group

Apical

group

Posterior

group

Supraclavicular

and infraclavicular

groups

Figure 4. Lymph nodes of the upper body.

Lower body

Palpate the superficial inguinal nodes (horizontal and vertical), which lie below the inguinal ligament

and near the great saphenous vein respectively, then the popliteal node in the popliteal fossa.

Conditions most likely to come up in a lump examination station

Epidermoid (sebaceous) cyst:

• Results from obstruction of sebaceous gland.

• May be red, hot, and tender.

• Spherical, smooth.

• Attached to the skin but not to the

underlying muscle.

• May have a punctum which may exude a

cottage cheese discharge.

Fibroma:

• Common and benign fibrous tissue tumour.

• Skin-coloured and painless.

• Can be sessile or pedunculated, ‘hard’ or

‘soft’.

• Situated in the skin and so unattached to

underlying structures.

Lipoma:

• Common and benign soft tissue tumour.

• Skin-coloured and painless.

• Spherical, soft and sometimes fluctuant.

• Not attached to the skin and therefore

mobile and ‘slippery’.

Skin abscess:

• Collection of pus in the skin.

• Very likely to be red, hot, and tender.

• May be indurated.

21Cardiovascular and respiratory medicine

Station 10

Chest pain history

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain that you are going to ask him some questions to uncover the nature of his chest pain,

and obtain his consent.

• Ensure that he is comfortable.

The history

• Name, age, occupation, and ethnic origin.

Presenting complaint and history of presenting complaint

• Ask about the nature of the chest pain. Use open questions and give the patient the time to

tell his story. Also remember to be empathetic: chest pain can be a very frightening experience.

• Elicit the patient’s ideas, concerns and expectations (ICE).

• As with any pain history, the mnemonic SOCRATES can help develop your differential diagnosis:

– Site: where exactly is the pain?

– Onset and progression: when did the pain start and how has it changed or evolved?

– Character: what type of pain is it (e.g. dull, sharp, or crushing)?

– Radiation: does the pain move anywhere (e.g. into the jaw, arm, or back)?

– Associated symptoms and signs: ask specifically aboutsweating, nausea and vomiting,shortness of breath, cough, haemoptysis, dizziness, and palpitations

– Timing and duration: does the pain occur at particular times of the day? How long does each

episode last?

– Exacerbating and alleviating factors: does anything make the pain better or worse (e.g. exercise, movement, deep breathing, coughing, cold air, large or spicy meals, alcohol, rest, GTN,

sitting up in bed)?

– Severity: “How would you rate the pain on a scale of 1 to 10, with 1 being no pain at all and 10

being the worst pain you have ever experienced?”

– effect on everyday life: ask in particular about exercise tolerance and sleep

• Ask about any previous episodes of chest pain.

Past medical history

• Current, past, and childhood illnesses.

• In particular, ask about risk factors: coronary heart disease, myocardial infarction, stroke, pneumonia, pulmonary embolism, deep vein thrombosis, hypertension, hyperlipidaemia, diabetes,

smoking, alcohol use, and recent long-haul travel.

• Recent trauma or injury.

• Surgery.

Drug history

• Prescribed medication, including the oral contraceptive pill if female.

• Over-the-counter medication.

• Illicit drugs.

• Allergies.

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Clinical Skills for OSCEs

14 Station 7

Intramuscular, subcutaneous, and intradermal

drug injection

Specifications: A model or skin pad in lieu of a patient.

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Discuss the procedure and obtain consent.

• Ask the patient if he has any allergies and what happens when he develops a reaction.

• Gather the appropriate equipment.

The equipment

• Patient’s drug chart • Non-sterile gloves

• British National Formulary (BNF) • Alcohol steret

• Drug • Cotton wool

• Diluent (usually sterile water or saline) • Plaster

• Appropriately sized syringe (e.g. 1 or 2 ml) • Sharps box

• 21G (green) needle and 23G (blue) or 25G (orange) needle*

*Note that the colour scheme for needles is not the same as that for cannulae (see Station 4)

The procedure

• Consult the prescription chart and check:

– the identity of the patient

– the prescription: validity, drug, dose, diluent (if appropriate), route of administration, date

and time of administration

– drug allergies, anticoagulation

• Consult the BNF and check the form of the drug, whether it needs reconstituting, the type and

volume of diluent required, and the speed of administration.

• Check the name, dose and expiry date of the drug on the vial, and ask another member of the

healthcare team to countercheck them.

• Wash your hands and don the gloves.

• Attach a 21G needle to the syringe and draw up the correct volume of the drug, making sure to

tap out and expel any air. For a powder, inject the appropriate type and volume of diluent into

the ampoule and shake until the powder has dissolved.

• Dispose of the needle and attach a new 23G needle to the syringe for IM/SC administration or

a 25G needle for ID administration.

• Ask the patient to expose his upper arm or leg and ensure that the target muscle is completely

relaxed.

• Identify landmarks in an attempt to avoid injuring nerves and vessels.

• Clean the exposed site with an alcohol steret and allow it to dry.

• Warn the patient to expect a ‘sharp scratch’.

Intramuscular (IM) injection technique

• For older children and adults, the densest portion of the deltoid muscle (above the armpit and

below the acromion) is the preferred IM injection site. The gluteal muscle is best avoided as the

General skills

Station 7 Intramuscular, subcutaneous, and intradermal drug injection 15

needle may not reach the muscle and there is a risk of damage to the sciatic nerve, not to mention

the general embarrassment of the thing. In infants and toddlers, the vastus lateralis muscle in the

anterolateral aspect of the middle or upper thigh is the preferred IM injection site.

• With your free hand, slightly stretch the skin at the site of injection.

• Introduce the needle at a 90 degree angle to the patient’s skin in a quick, firm motion.

• Pull on the syringe’s plunger to ensure that you have not entered a blood vessel. If you aspirate

blood, you need to start again with a new needle, and at a different site.

• Slowly inject the drug and quickly remove the needle.

Subcutaneous (SC) injection technique

• Bunch the skin between thumb and forefinger, thereby lifting the adipose tissue from the

underlying muscle (‘tenting’).

• Insert the needle, bevel uppermost, at a 45 degree angle in a quick, firm motion. You are aiming

for the tip of the needle to be in the ‘tent’.

• Release the skin.

• Pull on the syringe’s plunger to ensure that you have not entered a blood vessel.

• Slowly inject the drug.

Intradermal (ID) injection technique

• Stretch the skin taut between thumb and forefinger.

• Hold the needle so that the bevel is uppermost.

• Insert the needle at a 15 degree angle, almost parallel to the skin.

• Ensure that the needle is visible beneath the surface of the epidermis.

• Slowly inject the drug.

• A visible (and uncomfortable) bleb should form. If not, immediately withdraw the needle and

start again – you may have inserted the needle too deeply.

After the procedure

• Immediately dispose of the needle in the sharps box.

• Apply gentle pressure over the injection site with some cotton wool (the patient may assist

with this).

• Ensure that the patient is comfortable.

• Ask him if he has any questions or concerns.

• Thank him.

• Sign the prescription chart and record the date, time, drug, dose, and injection site of the injection in the medical records.

Figure 2. Intramuscular, subcutaneous, and intradermal injection techniques.

Intramuscular Subcutaneous Intradermal

Epidermis

Adipose tissue

Dermis

Muscle

90° 45° 15°

Clinical Skills for OSCEs

16 Station 8

Intravenous drug injection

Specifications: Anatomical arm in lieu of a patient. This station is likely to require you to demonstrate

and/or talk through the administration of an intravenous (IV) drug with a needle and syringe. There may

be a cannula in situ, enabling the drug to be administered through the cannula.

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Discuss the procedure and obtain consent.

• Ask the patient whether he has any allergies and what happens when he develops a reaction.

• Gather the appropriate equipment.

The equipment

• Patient’s drug chart • Non-sterile gloves

• British National Formulary (BNF) • Tourniquet

• Drug • Alcohol sterets

• Diluent (usually sterile water) • Cotton wool

• Appropriately sized syringes • Sharps box

• 21G (green) needle (×2)

The procedure

• Consult the prescription chart and check:

– the identity of the patient

– the prescription: validity, drug, dose, diluent (if appropriate), route of administration, date

and time of administration

– drug allergies

• Consult the BNF and check the form of the drug, whether it needs reconstituting, the type and

volume of diluent required, and the speed of administration.

• Check the name, dose and expiry date of the drug on the vial and the name and expiry date of

the diluent. Ask another member of the healthcare team to countercheck them.

• Wash your hands and don the gloves.

• Attach a 21G (green) needle to a syringe and draw up the correct volume of the diluent.

• Reconstitute the drug by injecting the diluent into the ampoule and shaking it until it is completely dissolved.

• Draw up the reconstituted drug into the same syringe, making sure to tap out and expel any air.

• Remove the needle and attach a new 21G needle to the syringe.

• Apply a tourniquet to the model arm and select a suitable vein.

• Clean the venepuncture site with an alcohol steret.

• Retract the skin with your non-dominant hand to stabilise the vein, tell the patient to expect a

‘sharp scratch’, and insert the needle into the vein until a flashback is seen.

• Undo the tourniquet.

• Administer the drug at the correct speed (too fast may cause adverse reactions such as emesis).

• Withdraw the needle and immediately dispose of it in the sharps box.

• Apply gentle pressure over the injection site using a piece of cotton wool.

• Remove the gloves.

cmecde 2052

 

• Remove the protective cap from the other end of the giving set.

• Squeeze and release the collecting chamber of the giving set until it is about half full.

General skills

Station 4 Cannulation and setting up a drip 9

• Open the regulating clamp and run fluid through the giving set to expel any air/bubbles.

• Close the regulating clamp.

• If using an extension ‘octopus’ connector, open and flush with normal saline so that no air

remains.

• Wash your hands (see Station 1) and follow the cannulation procedure above.

• Rather than capping the cannula immediately after removing the needle, connect the giving

set directly and flush with fluid from the bag.

• Apply the adhesive plaster or transparent film dressing to secure the cannula.

• Adjust the drip-rate (1 drop per second is equivalent to about 1 litre per 6 hours).

• Check that there is no swelling of the subcutaneous tissue i.e. that the line has not ‘tissued’.

• Tape the tubing to the arm.

After the procedure

• Discard clinical waste appropriately.

• Ensure that the patient is comfortable and inform him of possible complications (e.g. pain,

erythema).

• Thank the patient.

• Sign the fluid chart and record the date and time.

Examiner’s questions: complications of cannula insertion

• Infiltration of the subcutaneous tissue. • Phlebitis.

• Nerve damage. • Thrombophlebitis.

• Haematoma. • Septic thrombophlebitis.

• Embolism. • Local infection.

Clinical Skills for OSCEs

10 Station 5

Blood cultures

Before starting

• Introduce yourself to the patient, and confirm his name and date of birth.

• Explain the procedure and obtain his consent.

• Ask him which arm he prefers to have blood taken from.

• Ask him to expose this arm.

• Wash your hands.

• Gather the equipment in a clean tray.

The equipment

In a clean tray, gather:

• Aerobic and anaerobic blood culture bottles

• Winged collection set (or 18g needle and 20ml syringe)

• Apron

• Non-sterile or sterile gloves

• Disposable tourniquet

• Alcohol sterets (x2)

• Chlorhexidine sponge

• Sterile gauze

• Sharps bin

• For the blood culture bottles, check types (aerobic and anaerobic) and expiry dates, and ensure

that the broth is clear. Do not remove the barcodes.

Every effort to use aseptic technique should be made. If blood is being collected for other

tests, the blood culture sample should be collected first. Do not use existing peripheral lines

to obtain blood cultures. The most common skin contaminants include Staphyloccus

epidermidis, Corynebacterium spp., Propionibacterium spp., and Bacillus spp.

The procedure

• Decontaminate your hands.

• Position the patient so that his arm is fully extended. Ensure that he is comfortable.

• Select a vein by palpation: the bigger and straighter the better. The vein selected is most commonly the median cubital vein in the antecubital fossa.

• Release the tourniquet.

• Decontaminate your hands.

• Clean the venepucture site with the chlorhexidine sponge.

• Decontaminate your hands.

• Remove the flip tops from the culture bottles and disinfect the rubber caps each with a fresh

alcohol steret.

• Decontaminate your hands and don the apron and gloves.

• Warn the patient to expect a ‘sharp scratch’.

• Retract the skin to stabilise the vein and insert the butterfly needle into the vein.

• Fill each bottle with at least 10ml of blood, as per the markings on the bottle (let the vacuum in

the bottles do the job for you). Fill the aerobic bottle first to minimise the amount of air in the

anaerobic sample. If using a needle and syringe, collect at least 20ml of blood into the syringe

General skills

Station 5 Blood cultures 11

so as to inject a minimum of 10ml of blood into each bottle. (It is advised not to change needles

between drawing blood and injecting into culture bottles since the risk of needlestick injury

outweighs that of contamination of the sample with skin flora.)

• Release the tourniquet.

• Withdraw the needle and apply pressure to the puncture site.

• Unscrew the adaptor and immediately dispose of the needle in the sharps bin.

After the procedure

• Ensure that the patient is comfortable.

• Thank him.

• Dispose of clinical waste in a clinical waste bin.

• Decontaminate your hands.

• Label the bottles, including clinically relevant information e.g. the puncture site and any

antibiotics that the patient has been taking (ideally, blood cultures should be taken before the

administration of antibiotics; if not, they should be taken immediately before the next dose,

with the exception of children).

• Fill in a blood request form.

• Convey the samples to the microbiology laboratory without delay (or else incubate the bottles).

• Document the procedure.

Clinical Skills for OSCEs

12 Station 6

Blood transfusion

Specifications: This station requires you either to cannulate an anatomical arm and set up a blood

transfusion, or, more likely, simply to set up a blood transfusion. You may be instructed to talk through

parts of the procedure.

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain the requirement for a blood transfusion, explain the risks, and obtain his consent.

• Ensure that baseline observations have been recorded (pulse rate, blood pressure, and

temperature).

Cannulation

See Station 4.

Blood transfusion

1. Sample collection

• Re-confirm the patient’s name and date of birth and check his identity bracelet.

• Extract 10 ml of blood into a pink tube (some hospitals may require two tubes for new patients).

• Immediately label the tube and request form with the patient’s identifying data: name, date of

birth, and hospital number.

• Fill out a blood transfusion form, specifying the total number of units required.

• Ensure that the tube reaches the laboratory promptly.

2. Blood transfusion prescription

• Prescribe the number of units of blood required in the intravenous infusion section of the

patient’s prescription chart. Each unit of blood should be prescribed separately and be administered over a period of 4 hours.

• If the patient is elderly or has a history of heart failure, consider prescribing furosemide (loop

diuretic) with the second and fourth units of blood.

• Arrange for the blood bag to be delivered. The blood transfusion must start within 30 minutes

of the blood leaving the blood refrigerator.

3. Checking procedures

Ask a registered nurse or another doctor to go through the following checking procedures with you:

A. Positively identify the patient by asking him for his name, date of birth, and address.

B. Confirm the patient’s identifying data and ensure that they match those on his identity bracelet,

case notes, prescription chart, and blood compatibility report.

C. Record the blood group and serial number on the unit of blood and make sure that they match

the blood group and serial number on the blood compatibility report and the blood compatibility label attached to the blood unit.

D. Check the expiry date on the unit of blood.

E. Inspect the blood bag for leaks or blood clots or discoloration.

General skills

Station 6 Blood transfusion 13

4. Blood administration

• Attach one end of the transfusion giving set to the blood bag and run it through to ensure that

any air in the tubing has been expelled. Note that a transfusion giving set has an integral filter

and is not the same as a standard fluid giving set.

• Attach the other end of the giving set to the IV cannula which should be a grey (16G), wide-bore

cannula (minimum pink/20G, or larger for resuscitation situations).

• Adjust the drip rate so that the unit of blood is administered over 4 hours. Because one unit of

blood is 300 ml, and because 15 drops are equivalent to about 1 ml, this amounts to about 19

drops per minute.

• Sign the prescription chart and the blood compatibility report recording the date and time the

transfusion was started. The prescription chart and blood compatibility report should also be

signed by your checking colleague.

5. Patient monitoring

• Record the patient’s pulse rate, blood pressure, and temperature at 0, 15, and 30 minutes, and

then hourly thereafter.

• Ensure that the nursing staff observe the patient for signs of adverse transfusion reactions such

as fever, tachycardia, hypotension, urticaria, nausea, chest pain, and breathlessness.

• Make an entry in the patient’s notes, specifying the reason for the transfusion, the rate of the

transfusion, the total number of units given, and any adverse transfusion reactions.

Examiner’s questions: complications of blood transfusion

Immune • Acute haemolytic reaction, (usually due to ABO incompatibility).

•  Delayed haemolytic reaction, (usually due to Rhesus, Kell, Duffy,

etc., incompatibility).

•  Non-haemolytic reactions such as febrile reactions, urticarial

reactions, and anaphylaxis.

Infectious • Hepatitis.

• HIV/AIDS.

• Other viral agents.

• Bacteria.

• Parasites.

Cardiovascular • Left ventricular failure from volume overload.

Complications of massive

transfusion (>10 U)

• Hypothermia.

• Coagulopathy (from dilution of platelets and clotting factors).

• Acid–base disturbances.

• Hyperkalaemia.

• Citrate toxicity (from additive in bag of packed red blood cells).

• Iron overload.

Other • Air embolism.

• Thrombophlebitis.

cmecde 569

 

• The bottles appropriate for the tests that you are sending for (these vary from hospital to

hospital, but are generally yellow for biochemistry/U&Es, purple for haematology, pink for

group and save and crossmatch, blue for clotting/coagulation, grey for glucose, and black

for ESR)

• Cotton wool, swab, or gauze

• Tape or plaster

Make sure you have a yellow sharps box close at hand. The key to passing this station is

to be seen to be safe.

The procedure

• Wash your hands (see Station 1).

• Position the patient so that his arm is fully extended. Ensure that he is comfortable.

• Apply the tourniquet proximal to the venepuncture site.

• Select a vein by palpation: the bigger and straighter the better. The vein selected is most commonly the median cubital vein in the antecubital fossa.

• Don a pair of non-sterile gloves.

• Clean the venepuncture site with an alcohol steret. Explain that this may feel a little cold.

• Once the alcohol has dried off, attach the needle to the Vacutainer holder.

• Tell the patient to expect a ‘sharp scratch’.

• Retract the skin to stabilise the vein and insert the needle into the vein at an angle of 30–45

degrees to the skin.

Clinical Skills for OSCEs

6 Station 3 Venepuncture/phlebotomy

• Keeping the needle still, place a Vacutainer tube on the holder and let it fill.

• Once all the necessary tubes are filled, release the tourniquet. Remember that the tubes need

to be filled in a certain order (bottles with no additives first). See the guide to Vacutainer tubes

in Station 111.

• Remove the needle from the vein and apply pressure on the puncture site for at least 30

seconds (the patient may assist with this, or you may use tape or plaster).

• Immediately dispose of the needle in the sharps box.

• Remove and dispose of the gloves in the clinical waste bin.

Ensure that you release the tourniquet before removing the needle, and that you

immediately dispose of the needle in the sharps box.

After the procedure

• Ensure that the patient is comfortable.

• Thank the patient.

• Label the tubes (at least: patient’s name, date of birth, and hospital number; date and time of

blood collection).

• Fill in the blood request form (at least: patient’s name, date of birth, and hospital number; date

of blood collection; tests required).

• Document the blood tests that have been requested in the patient’s notes.

Examiner’s questions

If the veins are not apparent

• Lower the arm over the bedside.

• Ask the patient to exercise his arm by repeatedly clenching his fist.

• Gently tap the venepuncture site with two fingers.

• Apply a warm compress to the venepuncture site.

• Do not cause undue pain to the patient by trying over and over again (more than 2–3 times) –

call a more experienced colleague instead.

• Use femoral stab only as a last resort (usually in CPR situations).

In the event of a needlestick injury

• Encourage bleeding, wash with soap and running water.

• Immediately report the injury to your supervisor or the occupational health service.

• If there is a significant risk of HIV, post-exposure prophylaxis should be started as soon as

possible.

• Fill out an incident form.

For more information on the management of needlestick injury, refer to local or national protocols.

7General skills

Station 4

Cannulation and setting up a drip

Specifications: The station is likely to require you either to cannulate an anatomical arm and to put

up a drip, or simply to cannulate the anatomical arm. This chapter covers both scenarios.

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain the procedure and obtain his consent. For example, “I would like to insert a thin plastic

tube into one of the veins on your arm. The tube will enable you to receive intravenous fluids and

prevent you from becoming dehydrated. You may feel a sharp scratch when the needle is inserted,

but only the plastic tube will remain in the vein. Do you have any questions?”

• Ask him on which arm he would prefer to have the cannula.

• Ask him to expose this arm.

• Gather the equipment in a clean tray.

It is important to read the instructions for the station carefully. If, for example, the

instructions specify that the patient is under general anaesthesia, you are probably not

going to gain any marks for explaining the procedure.

Cannulation only

The equipment

In a clean tray, gather:

• A pair of non-sterile gloves

• A tourniquet

• Alcohol sterets or prepackaged chlorhexidine and alcohol sponge

• An IV cannula of appropriate size (Table 1). Size is primarily determined by the viscosity of

the fluid to be infused (e.g. blood requires pink or larger) and the required rate of infusion

• A pre-filled 5 ml syringe containing saline flush

• An adhesive plaster/transparent film dressing

• A sharps box

The procedure

• Wash your hands (see Station 1).

• Position the patient so that his arm is fully extended. Ensure that he is comfortable.

• Apply the tourniquet proximal to the venepuncture site.

• Select a vein by palpation: the bigger and straighter the better. Try to avoid the dorsum of the

hand and the antecubital fossa if possible (may be uncomfortable on flexion).

• Don a pair of non-sterile gloves.

• Clean the skin with an alcohol steret and let it dry.

• Remove the cannula from its packaging and remove its needle cap.

• Tell the patient to expect a ‘sharp scratch’.

• Anchor the vein by stretching the skin and insert the cannula at an angle of approximately 30

degrees.

• Once a flashback is seen, advance the whole cannula and needle by about 2 mm.

Clinical Skills for OSCEs

8 Station 4 Cannulation and setting up a drip

• Pull back slightly on the needle and continue to hold the needle while advancing only the

cannula into the vein.

• Release the tourniquet.

• Occlude the vein by pressing on the vein over the tip of the cannula.

• Remove the needle completely, and immediately put it into the sharps box.

• Cap the cannula with the same cap that was on the end of the needle.

• Apply the adhesive plaster or transparent film dressing to secure the cannula.

• Flush the cannula with 5 ml normal saline to prevent blood from occluding it.

Table 1. IV cannulae

Colour Size Water flow (ml/min)*

Blue

Pink (most common)

Green

Grey

Orange

22G

20G

18G

16G

14G

33

54

80

180

270

* Approximate values. According to Poiseuille’s Law, the velocity of a

Newtonian fluid through a cylindrical tube is directly proportional to the

fourth power of its radius.

After the procedure

• Dispose of clinical waste in a clinical waste bin.

• Ensure that the patient is comfortable and inform him of possible complications (e.g. pain,

erythema).

• Thank the patient.

Setting up a drip

The equipment

In a clean tray, gather:

• A pair of gloves • An adhesive plaster

• A tourniquet • A sharps box

• Alcohol sterets • An appropriate fluid bag

• An IV cannula of appropriate size • A giving set

The procedure

• Check the fluid prescription chart (if appropriate).

• Check the fluid in the bag (solution type and concentration) and its expiry date.

• Remove the fluid bag from its packaging and hang it up on a drip stand.

• Remove the giving set from its packaging. The regulating clamp for the IV line should be closed.

• Remove the protective covering from the exit port at the bottom end of the fluid bag.

• Remove the plastic cover from the large, pointed end of the giving set.

• Drive the large, pointed end of the giving set into the exit port at the bottom end of the fluid

bag.

cmecde 56

 

xiv OSCE tips

• Be nice to the patient. Have I already said this? Introduce yourself, shake hands, smile, even

joke if it seems appropriate – it makes life easier for everyone, including yourself. Remember to

explain everything to the patient as you go along, to ask him about pain before you touch him,

and to thank him on the second bell. The patient holds the key to the station, and he may hand

it to you on a silver platter if you seem deserving enough. That having been said, if you reach

the end of the station and feel that something is amiss, there’s no harm in gently reminding

him, for example, “Is there anything else that you feel is important but that we haven’t had time

to talk about?” Nudge-nudge.

• Take a step back to jump further. Last minute cramming is not going to magically turn you

into a good doctor, so spend the day before the exam relaxing and sharpening your mind. Go

to the country, play some sports, stream a film. And make sure that you are tired enough to fall

asleep by a reasonable hour.

• Finally, remember to practise, practise, and practise. Look at the bright side of things: at

least you’re not going to be alone, and there are going to be plenty of opportunities for good

conversations, good laughs, and good meals. You might even make lifelong friends in the process. And then go off to that Greek island.

1General skills

Station 1

Hand washing

Hands must be washed before every episode of care that involves direct contact with a patient’s skin,

their food or medication, invasive devices, or dressings, and after any activity or contact that potentially

contaminates the hands.

The procedure

• Your arms should be bare below the elbows: roll up your sleeves, remove your watch, any jewellery, and fake nails or nail varnish (fingernails should be kept short, ideally not exceeding 1mm

from the edge of the nail bed).

• Turn on the hot and cold taps with your elbows and thoroughly wet your hands once the water

is warm.

• Apply liquid soap (used in most hospital situations) or disinfectant from the dispenser (used

in the operating theatre). Disinfectants include pink aqueous chlorhexidine (‘Hibiscrub’) and

brown povidone iodine (‘Betadine’). Alcohol hand rubs offer a quicker alternative to liquid

soaps and disinfectants, though they should be applied for at least 20–30 seconds. Mere soap

bars are to be avoided.

• Wash your hands using the Ayliffe hand washing technique (see Figure 1 overleaf):

➀ palm to palm

➁ right palm over left dorsum and left palm over right dorsum

➂ palm to palm with fingers interlaced

➃ back of fingers to opposing palms with fingers interlocked

➄ rotational rubbing of right thumb clasped in left palm and left thumb clasped in right palm

➅ rotational rubbing, backwards and forwards, with clasped fingers of right hand in left palm

and clasped fingers of left hand in right palm

• Rinse your hands thoroughly.

• Turn the taps off with your elbows.

• Dry your hands with a paper towel and discard it in the foot-operated bin, remembering to use

the pedal rather than your clean hands!

• Consider applying an emollient if you have dry skin.

[Note] Alcohol hand rubs are ineffective against spores and should be avoided if there is contamination with biological

remnants such as faeces, blood, or urine; if there is visible dirt; or if the patient is infected with Clostridium difficile.

Clinical Skills for OSCEs

2 Station 1 Hand washing

Figure 1. Ayliffe hand washing technique:

1 Palm to palm

2 Right palm over left dorsum and left palm over right dorsum

3 Palm to palm fingers interlaced

4 Backs of fingers to opposing palms with fingers interlocked

5 Rotational rubbing of right thumb clasped in left palm and vice versa

6 Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice

versa

5 6

3 4

1 2

3General skills

Station 2

Scrubbing up for theatre

The equipment

• Scrubs • Sterile gown pack

• Theatre clogs or plastic overshoes • Sterile gloves

• Theatre cap • Brush packet containing a nail brush and

• Surgical mask nail pick

Before handwashing

State that you would:

• Change into scrubs and ensure that your arms are bare below the elbows.

• Exchange your shoes for theatre clogs or use plastic overshoes.

• Don a theatre cap, tucking all your hair underneath it.

• Enter the scrubbing room and put on a surgical mask, ensuring that it covers both your nose

and mouth.

• Depending on the clinical situation, consider wearing eye protection (goggles/visor).

• Open out a sterile gown pack on a clean, flat surface without touching the gown.

• Open out a pair of sterile gloves (in your size) using a sterile technique, letting them drop into

the sterile field created by the gown pack.

Handwashing

• Open a brush packet containing a nail brush and nail pick.

• Turn on the hot and cold taps and wait until the water is warm.

From here on, keep your hands above your elbows at all times.

The social wash

• Wash your hands with liquid disinfectant, either pink chlorhexidine (‘Hibiscrub’) or brown

povidone iodine (‘Betadine’), lathering up your arms to 2 cm above your elbows.

The second wash

• Use the nail pick from the brush packet to clean under your fingernails.

• Dispense soap onto the sponge side of the brush and use the sponge to scrub from your

fingertips to 2 cm above your elbows (30 seconds per arm).

Dispense soap using your elbow or a foot pedal, not your hands.

• To rinse, start from your hands and move down to your elbows so that the rinse water drips

away/down from your hands without re-contaminating them.

The third wash

• Using the brush side of the brush, scrub your fingernails (30 seconds per arm).

Clinical Skills for OSCEs

4 Station 2 Scrubbing up for theatre

• Using the sponge side of the brush, scrub:

– each finger and interdigital space in turn (30 seconds per arm)

– the palm and back of your hands (30 seconds per arm)

– your forearms, moving up circumferentially to 2 cm above your elbows (30 seconds per arm)

Remember to keep the brush well-soaped at all times.

• To rinse, start from your hands and move down to your elbows.

• Turn the taps off with your elbows.

After handwashing

• Use the two towels in the gown pack to dry your arms from the fingertips down (one towel

per arm).

• Pick up the gown from the inside and shake it open, ensuring that it does not touch anything.

• Put your arms through the sleeves, but do not put your hands through the cuffs.

• Put on the gloves without touching the outside of the gloves. Practise this – it’s not easy!

• Ask an assistant to tie up the inside of the gown, and to hold on to one side of the card (attached

to the front of the gown) while you rotate to tie up the outside of the gown yourself.

After scrubbing up, keep your hands in front of your chest and do not touch any non-sterile

areas, including your mask and hat.

5General skills

Station 3

Venepuncture/phlebotomy

Specifications: The station consists of an anatomical arm and all the equipment that might be

required. Assume that the anatomical arm is a patient and take blood from it.

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain the procedure and obtain his consent. For example, “I would like to take a blood sample

from you to check how your kidneys are working. This is a quick, simple, and routine procedure

which involves inserting a small needle into one of the veins on your arm. You will feel a sharp

scratch when the needle is inserted, and there may be a little bit of bleeding afterwards. Do you have

any questions?”.

• Ask him from which arm he prefers to have (or normally has) blood taken.

• Ask him to expose this arm.

• Gather the equipment in a clean tray.

The equipment

In a clean tray, gather:

• A pair of non-sterile gloves

• A tourniquet

• Alcohol wipes (sterets)

• A 23G (blue) needle/‘butterfly’ and Vacutainer holder