Excelling at Procedural Questions

Procedural questions are an interesting kettle of fish. Many people struggle with them. The reasons are varied - they haven't done the procedure before, or they often have done the procedure so much that it becomes second nature - stopping to then explain it can be tricky, let alone in a way which satisfies the examiners. 

The bad news about procedure questions is that they are an inevitable part of many oral exams. The good news is that they are very teachable. I like to compare them to a driving test - it isn't enough to simply drive the car to get a pass - you need to explicitly show your examiner that you know all the sequences in order, and that you don't miss out any steps. 

Let's have a look at a made-up question:

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Daniel Thomas, a 28-year-old helicopter pilot with a history of poorly managed asthma, presents to your ED via ambulance. He looks unwell, is gasping and only speaking in single words. On examination, he has decreased air entry on the right side, which is hyper-resonant to percussion, with tracheal deviation to the left. He has been given salbutamol nebulized and is on 15L non-rebreather mask oxygen. His respiratory rate is 28 and oxygenation is 93%. His heart rate is 90, and his blood pressure is 110/80. He has an IV in his left cubital fossa.

1. How would you manage Daniel? (4 mins)
2. Describe how you would insert a chest drain. (3 mins)
3. What is your long-term management for Daniel? (4 mins)

For question 2, I would expect an answer like this:

Preparation:

• Consent: Obtain informed consent if the patient can provide it.
• Sterilisation: Ensure a sterile environment with appropriate draping.
• Local Anaesthesia: Administer local anaesthesia (lidocaine) to the insertion site.

Assessment of Contraindications:

• Evaluate for any contraindications to chest drain insertion, such as coagulopathy or severe skin infection at the insertion site.
• Assess the patient’s coagulation status and platelet count if possible.

Procedure:

• Incision Site: Identify the fifth intercostal space in the mid-axillary line.
• Incision: Make a 2-3 cm horizontal incision above the rib to avoid the neurovascular bundle.
• Blunt Dissection: Use blunt dissection with a clamp to create a tract over the rib and into the pleural space.
• Chest Tube Insertion: Insert the chest tube using a curved clamp, directing it posteriorly and superiorly.
• Securing Tube: Secure the tube with sutures and connect it to an underwater seal drainage system.
• Dressings: Apply an occlusive dressing to the insertion site.

Adjuncts:

• Chest X-ray: Perform a chest X-ray to confirm the position of the chest tube and assess lung re-expansion.
• Analgesia: Provide adequate analgesia to manage pain associated with the procedure.

Monitoring:

• Monitor for complications such as infection, bleeding, or incorrect tube placement.
• Repeat imaging if there are clinical concerns about tube position or function.

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 There are a few things here to be aware of:

• Actually describing the procedure itself makes up a relatively small part of the marks. 
• If you have a memory blank on the day and forget a few steps, you can still score well, so long as you demonstrate structure and breadth.
• The examiners want to know that you are safe. They don't expect you to be an expert at the procedure, especially if it is a bit obscure.
• There are many other aspects to a procedure question - preparation, consent, contraindications, immediate confirmation of procedure and monitoring.
• If you learn how to perform a Seldinger technique (and learn to describe one), you can use this for many procedures - arterial lines, CVCs, chest drains, ascitic drains etc.

The structure for the above answer is a good one to commit to memory - because it demonstrates all the above and works for every procedure. You simply need to tailor the substance of the structure to your procedure in hand.

At PassAMC, our senior expert examiners will teach you all that you need to know for the AMC exams.