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Station 4: You are the SHO in charge of ICU.

Subject: Mr Lee Xin Yan 22 years old

Mr Lee was admitted to your hospital due to motor vehicle accident 3 days ago. He sustained a severe brain injury with massive intra-cranial haemorhage. He showed no sign of improvement. His sedation was off 24 hours ago and he showed no sign of waking up. Your consultant has reviewed him. He and another consultant have performed a few tests and confirmed that he is brain death. Currently, Mr Lee is being ventilated in ICU. You are asked to talk to his mother Madam Liu about the brain death and discuss with her the possibility of organ donation.

You have 14min until the patient leaves the room, followed by 1min for reflection before the discussion with the examiners.

Discussion:

    This type of question is always popular in MRCP PACES station 4. There are two tasks here, the first one- you are expected to break the bad news about brain death to Madam Liu about her son. The second task, you are supposed to discuss about organ donation with Madam Liu. A lot of candidates told me that they actually have problems to explain brain death to patient’s family members, therefore they couldn’t even start talking about organ donation.

I think it is a common dilemma in examination, you fail to convince patient’s mother that the patient is dead, how can you possibly proceed to tell her about organ donation.

The principles are simple, always do the following steps in your exam ( especially in breaking bad news!)

a) Assess your subject understanding about a situation

In this case, you can ask Madam Liu, “I know that you son was admitted to our hospital 3 days ago, did anyone inform you about his condition?”

b) Assess your subject about his/her expectation about a situation

You can ask Madam Liu,” Did you visit your son in ICU this morning, what do you think about his condition as compared when he was admitted?”
Madam Liu may tell you that she does not think that his son is improving, her answer can give you some ideas how to approach in the next step. If she think that her son ‘s condition is improving, you may need more time to explain some details such as CT scan reports etc to hint to her that her son is not doing well.

c)' Warming up'

You need to explain to your subject some information before breaking the bad news. In this case, you may say that “Our consultants have been reviewing him daily since he was admitted, they have reviewed his brain scan and actually they have done a few special tests, unfortunately, your son’s condition is not improving.” Always pause in between important sentences so that your subject can give you some feedbacks.

d) Go to your task

After seeing your subject’s respond to your explanation above, you then can break the bad news. Always remember to give your subject to breath and avoid bombarding him/her with a lot of technical details. Try to avoid medical jargon in exam!

You will be expecting that Madam Liu could not accept that her son is dead. You certainly should empathize with your subject and NEVER rush or push her to accept your explanation. Here comes the dilemma, the subject could not accept her son is dead, how do I talk about organ donation? You actually can explore some social history about Mr Lee. Actually, my friend failed this case in his MRCP PACES because he did not explore about the patient’s social history and found out that Mr Lee is the only child in the family.

After that, just tell Madam Liu that from the social history you gather from her , her son is a very helpful young man, you explain to her that even though Mr Lee is no more here, he is still able to help other needy people. Madam Liu may ask you the way to do this , then you can start the topic by saying ” Have you heard of organ donation before?”
So....., you see , the mission is accomplished! The rest of the topic such as “What is organ donation?” etc would be a simple job for you all!

Examine this lady's hand neurologically.

Discussion:   

  I think that this type of case is still a possiblilty in your MRCP PACES, although you are often see this case in Orthopedics ward rather than Medical ward. You notice this patient has right claw hand.Yes, you are right ,she has ulnar nerve palsy! Remember that ulnar nerve supplies all small muscles of the hand except LOAF ( the Lateral two lumbricals, Opponens pollicis, Abductor pollicis brevis and Flexor pollicis brevis). As a medical student before,you might still remember the function of lumbricals is to flex the metacarpophalageal joints and extend interphalageal joints of fingers except thumb. Therefore you see this this lady has claw hand involving only ring and little fingers. (because the lateral two lumbricals are supplied by median nerve)

In you exam, you must always try to find the underlying cause for this, if you look hard , you notice that there is a scar over the patient’s wrist. She actually sustained industrial injury before and there is injury of her ulnar nerve over her wrist. As you might remember, ulnar nerve enters the palm anterior to the flexor retinaculum alongside the lateral border of the pisiform bone and divides into superficial branch ( innervating the palmar aspect of the medial side of the little finger and the adjacent sides of the little and ring fingers) and the deep branch.( which supplies the small muscles of the hand).

If you ask the patient to grasp a piece of paper between the thumb and lateral aspect of the forefinger with each hand as below, you would be able to demonstrate Froment’s sign. You notice that the affected thumb will flex ( Flexor pollicis brevis) because of loss of the adductor of the thumb.

Common questions examiners would ask you,

1) What is ulnar nerve paradox?

2) All small muscles of hand are supplied by ulnar nerve except what muscles?

Conclusion:

This lady has right ulnar nerve palsy due to previous trauma

Extra points,

1) Besides the cutanous branch of superficial branch of the ulnar nerve, it also gives branch to supply palmaris brevis ( muscular branch). Related post, click here!

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