Difficult/Special Situations

Question 1

Signs of Abuse

Answer 1

• Verbally aggressive
• Tension between carer/pt
• Signs of stress
• Inconsistent accounts
• Defensive
• Disengaged
• Pt not left alone with staff
• Eveidence od psych disorder
• Evidence of intoxication

Question 2

Exam features - concern elder abuse

Answer 2

• Poor sanitation
• Signs of trauma
• Unexplained bruising
• Unexplained fractures
• Untreated physical conditions i.e. infections / pressure sores
• Restraint marks
• Wt loss
• Dehydration
• Malnutrition

Question 3

Advanced Care directive

Answer 3

• Situation where pt does not have capacity or abiltiy to communicate wishes
• Made when had capacity
• Signed and witnessed
• Applies to current siutation
• Clear and specific about treatments wanted or refused

Question 4

Capacity

Answer 4

Capacity refers to an adult’s ability to make a
decision for him or herself.
Capacity is specific to the particular decision that
needs to be made.

Evidence of capcity:
* understand/believe the facts involved in making the decision
* understand the main choices
* weigh up the consequences of the choices
* understand how the consequences affect them
* make their decision freely and voluntarily
* communicate their decision

Question 5

Bleeding in Jehovah’s witnesses

Answer 5

1. Haemostatic control
   a. IVF / IV colloid
   b. TXA 1g IV stat
   c. Desmopressin
   d. Avoid coagulopathy, hypothermia, acidosis
   e. Some products may be acceptable:
   - Vitamin K
   - Cryo
   - Factor VIII
2. Surgical control
   a. Cell salvage
   b. Less invasive technique - laparoscopic
   c. Tolerate less bleeding intra-op
   d.
3. Stimulate RBC production
   a. Fe Transfusion
   b. EPO
   c. B12 and folate

Question 6

Care of the dying

Answer 6

1. Acknowledge pt dying
2. Share with patient and designated relatives
3. Account for pt wishes / beliefs / faith / values
4. Anticipatory prescribing for symptom control
5. All further interventions reviewed in interest of patient
6. Nutritional needs assessed
7. Regular assessments
8. Care of patient immediately after death dignified

Question 7

Drug Seeker

Answer 7

1. Dvp rapport
2. Ensure no new organic pathology
3. Treat genuine pain
4. Onced rug seeking established -set clear limitations regarding meds sought
5. Consider open discussion w/ pt regarding their behaviour
6. Refer to D+A for ongoing Mx
7. Dvp Mx protocols for future attendances or agressive behaviours

Question 8

Frequent attender

Answer 8

1. Humane approach
2. Medical care follow standard procedures
3. Access to PMHx and community services involved in pt care
4. Dvp individ acute care plan to streamline assessment and Mx
5. MDT approach
6. Do not divert care away from ED - no benefit to pt

Question 9

Cultural Safety and competence

Answer 9

Cultural competence = set of behaviours + attitudes, skills and knowledge that allows an indivuidual to interect effectively in cross-cultural situation.
Respects and considers the patient’s cultural background, cultural beliefs and their values and appropriately tailors the way health
care is delivered to that individual.

Cultural safety = a way of practicing; recognising the impact of culture on professional practice
Measured from the patient’s perspective.

Unsafe cultural practice = any action that diminishes,
demeans or disempowers the cultural identity and well-being of an individual.

Question 10

Non Accidental Injury - Kids

Answer 10

History
No Hx / Inconsistent / Changing history
Inconsistent with child’s dvpt stage
Non-ambulatory Infant
Unwitnessed Trauma
Delay in seeking medical attention

Parental Factors - DV, young maternal age, Substance abuse, Mental Health Isuses, Known to DCJ, Previous Hx of abuse

Examination
Bruising
Any bruising < 4months
Bruising to trunk, ears, neck
Bruises to frenulum, auricular, cheek, eyes, sclera
Patterned bruising - linear, identifiable implement

Fracture Patterns
Metaphyseal lesion (bucket handle or corner #)
Ribs -post > lateral
Femoral fracture - non- ambulance child
Humeral - proximal / shaft < 3 years
Scapula, sternal and spinous process
Multiple fractures at various stage of healing
Complex skull fractures
Mulptiple presentations for fractures

Other
Eye - Retinal haemorrhages, SC haemorrhage, eye lid laceration
Burns - soles of feet, buttocks, back of hands
GI - visceral injury, duodenal haematoma, viscous perforation, pancreatitis with no explanation
Genitalia - injury, FGM, hymen perforation

DDx
True accidental injury
Osteogenesis imperfecta
Osteopaenia or rickets of prematurity
Metabolic - Scurvy, Copper deficiency
Chronic disease - liver/renal
Rashes - phytodermatitis, dermal melanocytes is, bulbous impetigo

Mx
Skeletal survey / CT head
Mandatory reporting
ID other children at risk
Admit - Paeds, Child protection, SW input
Documentation

Question 11

Elements of Verbal De-escalation

Answer 11

Safe Place

Safe space
- Remove agitated pts from waiting room
- Triage to be seen quickly
Posture
- Non-confrontational
Listen carefully
Acknowledge
- note frustration
Clarify limits and offer choices
- no violence tolerated
Exit strategy