10 advanced stations covering psychiatric emergencies, major haemorrhage, burns, spinal injuries, renal emergencies and more — all new topics not covered in Banks 1–4.
You are the ED doctor. Mr Victor Osei, 56 years old, presents with sudden onset severe chest pain that started 1 hour ago. He describes it as the worst pain he has ever felt.
Obs: BP Right arm 178/98, Left arm 142/86, HR 102, RR 20, SpO₂ 97%, Temp 37.0°C.
Please take a focused history from Mr Osei. You have 8 minutes.
⚠️ Examiner / Role-player Instructions — Not for Candidate
You are Victor Osei, a known hypertensive on amlodipine. The diagnosis is Type A aortic dissection. Pain started instantaneously — "like someone ripped my chest apart." It radiates straight through to the back between the shoulder blades. He has never had pain like this before. He is a tall, long-fingered man (undiagnosed Marfan's).
| Criterion | Marks |
|---|---|
| Pain Characterisation | |
| Tearing/ripping character specifically elicited — not crushing | 3 |
| Instantaneous maximum onset established | 2 |
| Radiation to back / interscapular region elicited | 2 |
| Dissection-Specific Features | |
| BP differential between arms noted / asked about (clinical finding noted in scenario) | 2 |
| Syncope / near-syncope asked and elicited | 1 |
| Neurological symptoms asked — limb weakness, facial droop, visual change | 1 |
| Pulse deficit / limb ischaemia asked | 1 |
| Connective Tissue / Risk Factors | |
| Marfan's features asked — height, arm span, lens problems, family history | 2 |
| Hypertension — established risk factor elicited | 1 |
| Family history of aortic disease / sudden cardiac death elicited | 1 |
| Cocaine use asked | 1 |
| Clinical Reasoning | |
| Correctly identifies aortic dissection as working diagnosis | 1 |
| States must exclude dissection before considering thrombolysis | 1 |
| Requests CT aortogram as investigation of choice | 1 |
| Total | 20 |
You are the ED doctor. Mr Reuben Clarke, 22 years old, has been brought to the ED by his mother. She is concerned he has been acting strangely for the past 3 weeks — staying in his room, talking to himself, and saying people are watching him through the TV.
He is currently calm and cooperative. Obs are normal. GCS 15.
Please take a focused psychiatric history from Reuben. You have 8 minutes.
⚠️ Examiner / Role-player Instructions — Not for Candidate
You are Reuben Clarke. You are guarded but cooperative if the candidate is non-threatening. You hear two voices (3rd person, talking about you — "he's a bad person"). You believe the TV is sending you personal messages. You smoke cannabis daily. You have not slept properly for 2 weeks. You have no thoughts of harming yourself or others. You dropped out of university 3 weeks ago.
| Criterion | Marks |
|---|---|
| Psychotic Symptoms | |
| Auditory hallucinations — number of voices, content, 2nd vs 3rd person, command hallucinations | 3 |
| Delusions of reference — TV messages elicited | 1 |
| Persecutory delusions — being watched elicited | 1 |
| Thought insertion / withdrawal / broadcasting asked | 1 |
| Negative symptoms — withdrawal, avolition, self-care, anhedonia elicited | 2 |
| Organic Causes | |
| Cannabis / substance use asked and quantified — daily use elicited | 2 |
| Other substances asked — stimulants, alcohol | 1 |
| Head injury, seizures, prescribed medications asked | 1 |
| Risk Assessment | |
| Suicidal ideation directly asked | 1 |
| Risk to others — command hallucinations specifically asked | 1 |
| Background | |
| Premorbid function — university dropout, social withdrawal established | 1 |
| Family psychiatric history — uncle's breakdown elicited | 1 |
| Non-judgemental, sensitive approach — maintains rapport throughout | 2 |
| Total | 20 |
A 35-year-old man, 80kg, has been brought to resus following a house fire. He has burns to his body. He is conscious, GCS 14, SpO₂ 94% on 15L O₂, HR 118, BP 102/68.
The examiner will describe the burn distribution. Please assess the burns systematically, calculate the TBSA%, classify burn depth, identify any airway concerns, and calculate his Parkland formula fluid requirement for the first 24 hours.
⚠️ Examiner Instructions — Not for Candidate
Read the burn description aloud. Ask the candidate to calculate Parkland fluids. Key assessment: airway recognition and correct Parkland calculation.
"He has singed eyebrows and nasal hair. His voice is hoarse. There is soot around his mouth and nose. Burns distribution: entire right arm (superficial partial thickness — blistered, pink, painful). Anterior chest (deep partial thickness — pale, reduced sensation). Both anterior thighs (superficial partial thickness — blistered). Perineum spared."
Follow-up Q1: "Calculate his TBSA and Parkland fluid requirement."
Expected: Right arm = 9%, Anterior chest = 9%, Both anterior thighs = 9% (4.5% each). Total TBSA = 27%. Parkland: 4 × 80 × 27 = 8,640 mL Hartmann's in 24 hours. Half (4,320 mL) in first 8 hours from time of burn; half (4,320 mL) in next 16 hours.
Follow-up Q2: "What is your most urgent action right now?"
Expected: Secure the airway immediately — hoarse voice + singed hair + carbonaceous sputum + enclosed space = inhalation injury. Call anaesthetics for immediate RSI before progressive oedema closes the airway. High-flow oxygen (carbon monoxide poisoning possible — 100% O₂ via NRB).
| Criterion | Marks |
|---|---|
| Airway Assessment | |
| Immediately identifies airway at risk — singed hair, hoarse voice, carbonaceous sputum | 2 |
| Calls anaesthetics for early intubation — does not delay | 2 |
| 100% O₂ via NRB — carbon monoxide poisoning considered | 1 |
| TBSA Calculation | |
| Uses Rule of Nines correctly — right arm 9%, anterior chest 9%, anterior thighs 9% | 3 |
| Correct total TBSA — 27% | 2 |
| Correctly excludes superficial (epidermal) burns from TBSA calculation | 1 |
| Burn Depth Classification | |
| Correctly classifies superficial partial thickness and deep partial thickness features | 2 |
| Parkland Formula | |
| Correct formula stated — 4 ml × weight × %TBSA | 1 |
| Correct calculation — 8,640 mL Hartmann's | 2 |
| Correct fluid timing — half in first 8 hours from burn time, half in next 16 hours | 2 |
| Burns unit referral criteria stated — >10% TBSA, inhalation, face/hands | 1 |
| Urine output target stated — 0.5–1 mL/kg/hr to guide fluid titration | 1 |
| Total | 20 |
A 28-year-old woman was involved in a rear-end RTC 2 hours ago. She has neck pain and was brought in with a hard collar in situ. GCS is 15, she is alert and cooperative. She has no distracting injuries and is not intoxicated.
Please perform a clinical cervical spine assessment using the NEXUS criteria and Canadian C-Spine Rule, and decide whether imaging is required. The examiner will give findings as you examine.
⚠️ Examiner Instructions — Not for Candidate
Feed findings as candidate examines. This patient has midline C5 tenderness — collar cannot be removed clinically. CT C-spine required. Ask: "The CT is reported as normal but she has tingling in both hands — what do you do?" (SCIWORA — urgent MRI.)
| Criterion | Marks |
|---|---|
| Framework Application | |
| States NEXUS criteria — lists all 5 correctly | 3 |
| Confirms GCS 15, no intoxication, no distracting injury — 3 criteria met | 1 |
| Examination Technique | |
| Maintains MILS throughout collar removal — does not remove collar without MILS | 2 |
| Palpates all midline cervical spinous processes C1–C7 systematically | 2 |
| Correctly identifies midline C5 tenderness — NEXUS criterion failed | 2 |
| Does NOT test ROM — correctly withholds due to midline tenderness | 2 |
| Neurological Assessment | |
| Full upper and lower limb neurological exam — power, sensation, reflexes | 2 |
| Checks for priapism — cord injury marker | 1 |
| Imaging Decision & SCIWORA | |
| Correct decision — CT C-spine required, cannot clear clinically | 1 |
| SCIWORA — normal CT with neurological deficit requires urgent MRI | 2 |
| Collar maintained until imaging reviewed and cleared | 1 |
| Total | 20 |
A 67-year-old man with COPD and increasing breathlessness requires an arterial blood gas sample. He is on warfarin for AF (INR 2.4 last week).
Please demonstrate radial artery ABG sampling on this manikin. Talk through each step including site selection, Allen's test, technique and post-procedure care. State complications specific to this patient.
⚠️ Examiner Instructions — Not for Candidate
Assess Allen's test performance, needle angle and technique, air expulsion, and pressure duration. Ask: "Allen's test is negative — the hand does not flush. What do you do?" (Choose alternative site — femoral or other arm.)
| Criterion | Marks |
|---|---|
| Preparation | |
| Consent, checks anticoagulation status — notes warfarin, plans extended pressure | 2 |
| Correct equipment — pre-heparinised syringe or heparin flush | 1 |
| Wrist hyperextended correctly — rolled towel or assistant | 1 |
| Allen's Test | |
| Allen's test performed correctly — both arteries compressed, fist made, ulnar released | 3 |
| Correctly interprets positive result — flush <7 seconds, safe to proceed | 1 |
| States action if negative — alternative site selected | 1 |
| Technique | |
| Palpates radial pulse with 2 fingers, cleans site | 1 |
| Correct needle angle — bevel up, 45° (30–60° acceptable) | 1 |
| Identifies pulsatile bright red blood — arterial confirmation | 1 |
| Air expelled immediately, syringe capped, rolled between palms | 2 |
| Post-Procedure | |
| Firm pressure applied — states minimum 10 minutes given warfarin | 2 |
| Complications specific to anticoagulated patient stated — haematoma risk | 1 |
| Sample labelled with FiO₂, analysed within 15 minutes or on ice | 1 |
| Checks for haematoma / neurovascular status after procedure | 1 |
| Total | 20 |
A 38-year-old man is brought to resus following a high-speed RTC. He has an open femoral fracture with active arterial bleeding. He is pale, sweaty and confused. BP 72/40, HR 148, SpO₂ 92%, GCS 12.
Please talk the team through your immediate management, including haemorrhage control, activation of the major haemorrhage protocol, and your damage control resuscitation strategy. You have 8 minutes.
⚠️ Examiner Instructions — Not for Candidate
Key assessment: does candidate apply tourniquet first and activate MHP early? Ask: "A junior says to give 2 litres of normal saline first — what do you think?" (Incorrect — blood products in 1:1:1 ratio, not crystalloid. Crystalloid worsens dilutional coagulopathy.) Also ask about TXA timing.
| Criterion | Marks |
|---|---|
| Haemorrhage Control | |
| Tourniquet applied proximally — time documented | 2 |
| Wound packing with haemostatic gauze stated | 1 |
| Major Haemorrhage Protocol | |
| MHP activated immediately — contacts blood bank | 2 |
| 1:1:1 ratio blood products stated — pRBC:FFP:platelets | 2 |
| Correctly rejects crystalloid-first approach — explains dilutional coagulopathy | 2 |
| Damage Control Resuscitation | |
| Permissive hypotension — target SBP 80–90 until surgical haemostasis | 2 |
| Tranexamic acid — 1g IV within 3 hours, correct dose and timing | 2 |
| Calcium replacement with transfusion — 10% calcium chloride dose stated | 1 |
| Lethal triad recognised — hypothermia, acidosis, coagulopathy — active warming | 2 |
| Fibrinogen target >1.5 g/L — cryoprecipitate if low | 1 |
| Urgent surgical/orthopaedic referral — haemostasis is definitive treatment | 1 |
| Total | 20 |
Mrs Nadia Patel, 42 years old, has a dislocated right hip following a fall. She needs procedural sedation in the ED for hip reduction. She is anxious and has never had sedation before. She has a nut allergy and last ate a sandwich 3 hours ago.
Please obtain valid informed consent for procedural sedation from Mrs Patel. You have 8 minutes.
⚠️ Examiner / Role-player Instructions — Not for Candidate
You are Nadia Patel. You are in pain and nervous. Ask: "Will I be unconscious?" "What if I stop breathing?" "I ate 3 hours ago — is that safe?" "I'm allergic to nuts — does that matter?" If candidate explains clearly and addresses your concerns, become reassured. If rushed, remain anxious and ask more questions.
| Criterion | Marks |
|---|---|
| Capacity & Setting | |
| Confirms patient has capacity — understands, can make decision | 1 |
| Private setting, introduces self and role, checks patient's current understanding | 1 |
| Explaining the Procedure | |
| Explains why needed — hip needs to be relocated, sedation allows this safely | 1 |
| Explains sedation clearly — "twilight," relaxed but not fully asleep, aware but comfortable | 2 |
| Explains monitoring — oxygen, pulse, BP, doctor present throughout | 1 |
| Risks & Benefits | |
| Common risks — drowsiness, nausea, paradoxical agitation explained | 2 |
| Serious risk — respiratory depression explained simply, reassures monitoring in place | 2 |
| Fasting — addresses 3-hour concern honestly, explains risk/benefit decision | 2 |
| Nut allergy addressed — asks about drug allergies, notes propofol caution | 2 |
| Alternatives & Aftercare | |
| Alternatives mentioned — nerve block, general anaesthesia, delay | 1 |
| Post-sedation advice — no driving, need escort home for 24 hours | 1 |
| Checks understanding, invites questions, obtains verbal/written consent | 2 |
| Non-anxious, clear communication — patient reassured | 1 |
| Total | 20 |
You are the ED registrar. Mr Harold Booth, 81 years old, has been brought in with an acute exacerbation of his end-stage COPD. He has metastatic lung cancer (diagnosed 3 months ago, not for active treatment), heart failure and is frail and bedbound at baseline. His daughter Mrs Jennifer Booth is present.
He is currently drowsy but rousable, GCS 12. He has previously expressed to his GP that he would not want to be resuscitated. There is no DNACPR form in his notes.
Please have a DNACPR discussion with his daughter. You have 8 minutes.
⚠️ Examiner / Role-player Instructions — Not for Candidate
You are Jennifer Booth. You are tearful and frightened. You love your father deeply. Initially say: "I want everything done for him — please don't give up on him." If candidate explains clearly and compassionately, soften. Then ask: "But what if he arrests — are you really not going to try?" Test whether candidate holds firm while remaining empathic. Do not accept the decision easily — provide realistic pushback.
| Criterion | Marks |
|---|---|
| Setting & Opening | |
| Private, sits down, empathic opening — acknowledges how difficult this is | 1 |
| Establishes what daughter already knows about father's condition | 1 |
| Clinical Context | |
| Explains clinical situation clearly — end-stage COPD, metastatic cancer, frailty | 2 |
| Explains CPR honestly — chest compressions, shocks, breathing tube — what it involves | 2 |
| Explains realistic outcome — very unlikely to survive, likely to cause harm | 2 |
| Patient's Wishes | |
| References patient's previously expressed wish not to be resuscitated | 2 |
| Explains DNACPR applies only to cardiac arrest — all other treatment continues | 2 |
| Handling Family Response | |
| Does not tell family it is their decision — clarifies it is a clinical decision | 2 |
| Remains compassionate but clear when family pushes back | 2 |
| Offers second opinion / senior review / PALS if family remains unhappy | 1 |
| Mentions ReSPECT form / advance care planning going forward | 1 |
| Allows silence, acknowledges grief — does not rush | 1 |
| Does not use jargon — checks understanding throughout | 1 |
| Total | 20 |
A 68-year-old man with CKD stage 4 and type 2 diabetes presents feeling generally unwell with muscle weakness and palpitations for 2 days. He takes ramipril, spironolactone and metformin.
Obs: HR 52 (irregular), BP 148/90, SpO₂ 97%, GCS 15.
The examiner will give you his bloods and ECG. Interpret them systematically and outline your stepwise management. This is a time-critical station.
⚠️ Examiner Instructions — Not for Candidate
Read results and ECG aloud. Key assessment: calcium gluconate first before anything else. Ask: "A nurse asks if she should give the insulin now — what do you say?" (Only after calcium gluconate is given.) Also ask about monitoring for hypoglycaemia after insulin.
Bloods: K⁺ 7.2 mmol/L (↑↑), Na 136, Urea 28.4 (↑↑), Creatinine 412 (↑↑ — AKI on CKD), pH 7.22, HCO₃ 14 (metabolic acidosis), eGFR 11, Glucose 8.2, CK 320.
ECG: Bradycardia 52 bpm, irregular. Absent P waves. Markedly widened QRS (160ms). Tall peaked T waves in precordial leads. No sine wave pattern yet.
Follow-up Q1: "What is your first drug and why?"
Expected: Calcium gluconate 10 mL 10% IV — membrane stabilisation. Prevents VF. Does not lower K⁺ but protects heart immediately. Must be given before insulin/glucose.
Follow-up Q2: "After insulin-dextrose, what monitoring is required and for how long?"
Expected: BM monitoring every hour for 6 hours — significant hypoglycaemia risk 1–2 hours post-insulin.
| Criterion | Marks |
|---|---|
| Data Interpretation | |
| Identifies severe hyperkalaemia — K⁺ 7.2 | 1 |
| AKI on CKD recognised — creatinine 412, urea 28.4, eGFR 11 | 1 |
| Metabolic acidosis identified — contributes to K⁺ elevation | 1 |
| ECG Interpretation | |
| Absent P waves identified | 1 |
| Widened QRS (160ms) identified — life-threatening feature | 2 |
| Peaked T waves identified | 1 |
| Recognises ECG as life-threatening — immediate treatment required | 1 |
| Treatment — correct order scores marks | |
| Calcium gluconate FIRST — membrane stabilisation, dose and route correct | 3 |
| Insulin + dextrose — 10 units Actrapid, correct glucose preparation | 2 |
| Sodium bicarbonate — given for metabolic acidosis | 1 |
| Salbutamol nebuliser as adjunct | 1 |
| Nephrology referral for dialysis — definitive treatment | 1 |
| Offending drugs stopped — ramipril, spironolactone | 1 |
| BM monitoring hourly for 6 hours post-insulin | 2 |
| Total | 20 |
A 6-year-old boy, 22 kg, is brought to resus after being struck by a car at 30 mph. He was thrown 3 metres. He was crying at the scene but is now quiet and pale.
The examiner will give you his primary survey findings. Interpret each finding against paediatric normal ranges, identify life threats and state your immediate management for each.
⚠️ Examiner Instructions — Not for Candidate
Read findings aloud. Ask candidate to interpret each value against normal ranges, identify life threats, and give weight-based management. Ask: "Why are children deceptive in haemorrhagic shock?" (They compensate — maintain BP until late decompensation, then crash suddenly.)
A: Airway open, no stridor, C-spine immobilised.
B: RR 36 (↑), SpO₂ 91% on air. Reduced air entry left base. Trachea central. Dull to percussion left base.
C: HR 148 (↑), BP 82/54 (↓ — at lower limit for age). CRT 4 seconds centrally. Pale, cold peripheries. Abdomen — bruising across left upper quadrant (seat belt sign). Tender left upper quadrant.
D: GCS 11 (E3V3M5). Pupils equal and reactive. BM 4.8.
E: Temp 35.8°C. Bruising L upper quadrant. Pelvis stable. Long bones intact.
Follow-up Q1: "What are the two immediate life threats and how do you manage them?"
Expected: (1) Left haemothorax — chest drain (22 kg child: 20Fr drain, BTS formula: size = 4 × weight^0.5, or use tube size = age/2 + 8). (2) Intra-abdominal haemorrhage (splenic injury likely — seat belt sign, LUQ bruising, haemodynamic shock) — 10 mL/kg 0.9% NaCl IV/IO, activate MHP, urgent CT abdomen, surgical referral.
Follow-up Q2: "Should you give him 3 boluses of saline before blood?"
Expected: No — in haemorrhagic trauma, limit crystalloid. 1–2 boluses maximum then blood (O-negative 10 mL/kg). Avoid dilutional coagulopathy. Damage control resuscitation applies in children too.
| Criterion | Marks |
|---|---|
| A & B Assessment | |
| Airway confirmed — C-spine immobilised throughout | 1 |
| RR 36 identified as tachypnoeic for age (normal 20–30) | 1 |
| Left haemothorax identified — dull, reduced air entry, SpO₂ 91% | 2 |
| Immediate intervention — high-flow O₂, chest drain left side, correct size for child | 2 |
| C Assessment | |
| HR 148 identified as tachycardic (normal 80–120 for age) | 1 |
| BP 82/54 interpreted correctly — at lower limit for age, compensated shock | 2 |
| Intra-abdominal injury suspected — seat belt bruising, LUQ tenderness, haemodynamic instability | 2 |
| Fluid resuscitation — 10 mL/kg (220 mL) 0.9% NaCl IV/IO bolus | 2 |
| Blood transfusion — O-negative 10 mL/kg after 1–2 crystalloid boluses | 1 |
| D, E & Overall | |
| GCS 11 — reduced consciousness, head injury considered | 1 |
| Hypothermia 35.8°C — active warming stated | 1 |
| Children compensate in shock — explains deceptive nature, late decompensation | 2 |
| Urgent CT trauma and surgical/paediatric surgery referral | 1 |
| NAI considered and mentioned given mechanism and bruising pattern | 1 |
| Total | 20 |