OSCEs II: Practical procedures, prescribing and acute care stations

🩺 OSCEs II: practical procedures, prescribing and acute care stations. The GMC's MLA requires every UK graduate to be competent in a defined list of practical skills and procedures, to prescribe safely, and to assess and manage an acutely unwell patient. OSCEs test these with mannequins, simulated patients and real drug charts. This chapter covers the core procedures step by step, safe prescribing and fluid stations, ABCDE assessment of the deteriorating patient, cardiac arrest and other emergency simulations, with worked examples of the commonest stations.
Your four questions for any practical or acute station: Have I confirmed identity, consent, allergies and indication? Am I following aseptic and sharps safety? What is the most dangerous problem right now (ABCDE), and have I called for help early? Have I documented, handed over and planned review?

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Principles for Every Procedure

• Before: introduce, identify the patient (name, DOB, wristband), explain the procedure, its purpose and risks, gain consent; check allergies (latex, chlorhexidine, iodine, local anaesthetic), anticoagulants and bleeding risk where relevant; check for contraindications; prepare equipment on a clean tray or trolley; hand hygiene; PPE (gloves, apron, eye protection as needed).
• During: aseptic non-touch technique (ANTT) - protect key parts and key sites; standard ANTT for most procedures, surgical ANTT for complex ones (central lines, catheterisation in some trusts); skin cleaning with 2% chlorhexidine in 70% alcohol (allow to dry for 30 seconds); communicate with the patient throughout.
• Sharps - never resheath needles; dispose of sharps immediately at the point of use into a sharps bin you have brought with you; if a needlestick occurs - encourage bleeding, wash with soap and water, report, occupational health/ED for risk assessment (PEP within hours for HIV).
• After: make the patient comfortable, dispose of waste correctly (clinical waste), hand hygiene, label samples at the bedside, document (date, time, procedure, indication, consent, complications, your name and signature), and arrange follow-up of results.
• In the OSCE - verbalise what you would do on a mannequin ("I would now check the patient's identity against the wristband").

Venepuncture, Blood Cultures and Cannulation

• Venepuncture:
  • Identify the patient and indication, check allergies and anticoagulants, consent; select tubes (correct order of draw).
  • Apply a tourniquet 7–10 cm above the site; select a vein (antecubital fossa - median cubital vein); clean the site and allow to dry; do not re-palpate.
  • Anchor the vein, insert the needle bevel up at 15–30°; attach bottles in order; release the tourniquet before removing the needle; apply pressure with gauze; dispose of the needle immediately; invert tubes gently; label at the bedside; complete request forms.
• Blood cultures: ideally before antibiotics; aseptic technique (2% chlorhexidine/70% alcohol, allow to dry); clean the bottle tops with a separate alcohol wipe; with a butterfly needle and blood culture adaptor, fill the aerobic bottle first (air in the tubing), then anaerobic; 8–10 mL per bottle; then other tubes; label (not over the barcode), document time and site; send promptly.
• IV cannulation:
  • Check indication, identity, consent, allergies; choose size (18G green or 16G grey for rapid fluids/blood; 20G pink for most IV drugs; 22G blue for fragile veins).
  • Tourniquet, select a straight vein in the forearm or back of the hand (avoid joints, AV fistula arm, side of axillary clearance, infected or injured skin), clean and allow to dry.
  • Insert bevel up at 10–30°, watch for flashback, advance a further 2 mm, advance the cannula off the needle, release the tourniquet, occlude the vein above the tip, remove the needle and dispose of it, cap the cannula, secure with a sterile dressing, flush with 5–10 mL 0.9% saline (check for pain or swelling - extravasation), date the dressing and document (VIP score daily; remove when not needed).

Injections, IV Drugs and Fluids Set-up

• Check before any drug administration - the "rights": right patient, right drug, right dose, right route, right time, right indication, allergies, expiry date, and the drug chart signed by a prescriber; two-person checks for controlled drugs and some IV drugs.
• Intramuscular injection - deltoid (up to 1 mL; e.g. vaccines), vastus lateralis or ventrogluteal (larger volumes); Z-track technique for irritant drugs; 90° angle, aspirate if required by local policy, inject slowly; IM adrenaline for anaphylaxis - anterolateral thigh.
• Subcutaneous injection - abdomen or thigh, pinch a skin fold, 45–90°; e.g. LMWH, insulin (rotate sites to avoid lipohypertrophy).
• Preparing an IV infusion - check compatibility, dilute per guidance (e.g. local IV monographs/Medusa), label the bag (drug, dose, diluent, volume, patient, date, time, signatures), prime the giving set (no air), connect via ANTT, set rate on a pump; observe for reactions.
• Setting up a fluid giving set - check the prescription and bag (type, volume, expiry, clear, intact), spike the bag, fill the drip chamber about half, prime the line, connect, set the rate (gravity: drops per minute = volume (mL) × drop factor (20 drops/mL for crystalloid) ÷ time (minutes); usually via a volumetric pump).

Urinary Catheterisation

• Indications - acute or chronic retention, accurate output monitoring in critical illness, perioperative, bladder irrigation (clot retention), some incontinence where other options fail (pressure ulcers). Avoid unnecessary catheters (CAUTI risk).
• Contraindications - suspected urethral injury (blood at the meatus after pelvic trauma) - urology referral.
• Procedure (male): consent and chaperone; check allergies (latex, chlorhexidine, lidocaine); position supine; prepare a sterile field (surgical ANTT); retract the foreskin and clean the glans and meatus (from meatus outwards) with saline or chlorhexidine; instil lidocaine gel (e.g. Instillagel) and wait 3–5 minutes; hold the penis upright, insert the catheter (12–14Ch for most adults) until urine flows, then advance to the hilt; inflate the balloon with the stated volume of sterile water only once urine flows; withdraw gently until resistance; connect to a drainage bag below bladder level; replace the foreskin (prevent paraphimosis); measure residual volume.
• Female: labia separated, clean front to back, identify the meatus (above the vagina), insert about 5–7 cm until urine flows then a little further before inflating.
• Document - indication, consent, catheter type and size, batch number, balloon volume, residual volume, complications, and a removal plan (trial without catheter).
• Problems - no urine (check position, flush, bladder scan), pain on balloon inflation (deflate - probably in the urethra), bypassing, haematuria (often minor), CAUTI, post-obstructive diuresis after chronic retention (monitor fluid balance and U&E).

ABG Sampling, ECG Recording and Bedside Tests

• Arterial blood gas sampling (radial): consent (it is painful); check anticoagulation and clotting; modified Allen's test is often described (occlude both radial and ulnar arteries, release the ulnar - colour should return within 5–15 seconds), though its value is debated; wrist slightly extended; clean; local anaesthetic; heparinised syringe, needle at 30–45° towards the pulse; the syringe fills under arterial pressure; remove and apply firm pressure for at least 5 minutes; expel air, cap, analyse within 10–15 minutes; record FiO₂ and temperature.
• 12-lead ECG recording: explain, expose the chest, patient lying at 45° and relaxed; skin preparation; limb electrodes (red - right arm, yellow - left arm, green - left leg, black - right leg: "ride your green bike"); chest electrodes - V1 4th intercostal space right sternal edge, V2 4th ICS left sternal edge, V4 5th ICS mid-clavicular line, V3 between V2 and V4, V5 anterior axillary line at the level of V4, V6 mid-axillary line at the same level; check calibration (25 mm/s, 10 mm/mV); label with patient details, date, time and symptoms; show to a senior if abnormal.
• Capillary blood glucose - wash hands (patient's), side of the fingertip, discard first drop if contaminated, check the meter is calibrated; act on hypo- or hyperglycaemia; ketones if >11 mmol/L in type 1 diabetes or unwell.
• Urinalysis - fresh mid-stream sample, dip and read at the stated times, interpret (leucocytes, nitrites, blood, protein, glucose, ketones, pH, specific gravity) and pregnancy test where relevant.
• Peak flow, inhaler technique and spacer - three attempts, best of three; compare with predicted or best; demonstrate inhaler technique (pMDI: shake, breathe out, seal lips, press and breathe in slowly and deeply, hold for 10 seconds; spacer - tidal breathing for children).
• Observations and NEWS2 - respiratory rate, SpO₂ (scale 1 or 2 for target 88–92%), oxygen use, systolic BP, pulse, consciousness (ACVPU - new confusion scores 3), temperature; a score of 5–6 (or 3 in one parameter) - urgent review; ≥7 - emergency response (critical care outreach).

Other MLA Procedures

• The GMC practical skills and procedures list (2024 graduates onwards) includes, among others: taking a history and examining, measuring observations, venepuncture, blood cultures, cannulation, IV infusion set-up and drug preparation, IM/SC/intradermal injections, urinary catheterisation, ABG sampling, ECG recording, blood glucose, urinalysis, peak flow, inhaler technique, basic and immediate life support, oxygen therapy, nasogastric tube placement checks, suturing and wound care (skin closure with sutures and steri-strips), local anaesthetic infiltration, airway adjuncts and bag-valve-mask ventilation, transfusion (safe practice - pre-transfusion checks), hand hygiene and PPE, surgical scrubbing, swabs (wound, nose, throat) and pregnancy testing. Check the current GMC list, which is updated periodically.
• NG tube position check - pH of aspirate ≤5.5 (first-line) or chest X-ray (if no aspirate or pH >5.5) before any use; never use the "whoosh" test, litmus paper or bubbling under water (never events - NHS Improvement).
• Suturing (simple interrupted) - consent, check tetanus status, clean and irrigate, local anaesthetic (lidocaine 1% - maximum 3 mg/kg without adrenaline, 7 mg/kg with adrenaline; adrenaline-containing preparations in digits are now considered safe by many specialists, but follow local policy), enter at 90°, equal bites from each edge, evert the edges, instrument tie, cut leaving 3–5 mm tails; dressing; removal - face 3–5 days, scalp and trunk 7–10 days, limbs 10–14 days.
• Blood transfusion - the most important step is positive patient identification at sample taking and at the bedside (ask the patient to state name and DOB, match with wristband, prescription and unit); observations before, at 15 minutes and at the end; stop and assess if a reaction occurs (fever, rash, hypotension, breathlessness, back pain - ABO incompatibility is a never event).

Safe Prescribing Stations

• Stations - write a drug chart (regular, as-required, once-only), review a chart for errors, prescribe for a scenario (pain, nausea, VTE prophylaxis, antibiotics, fluids, insulin), calculate doses, and complete a discharge prescription. The Prescribing Safety Assessment (PSA) is a separate national assessment for UK final-year students and foundation doctors.
• Check before prescribing: patient identity and weight, allergies (and the reaction), renal and liver function, pregnancy and breastfeeding, current medications and interactions (BNF), indication.
• Writing a prescription: patient details on every page; approved (generic) drug name in capitals; dose (avoid unnecessary decimal points - "5 mg" not "5.0 mg"; never abbreviate "micrograms" or "units"); route; frequency and times; start date; duration or review date (antibiotics); indication; your signature, printed name, bleep and date. Controlled drugs on discharge need total quantity in words and figures.
• Common prescribing errors - wrong dose (10-fold errors), missing allergy check, duplicate prescriptions (paracetamol in combination products), interactions (warfarin with antibiotics; clarithromycin with statins; trimethoprim with methotrexate; NSAIDs with ACE inhibitors and diuretics - "triple whammy" AKI), prescribing nephrotoxic drugs in AKI (stop NSAIDs, ACE inhibitors/ARBs, diuretics, metformin (risk of lactic acidosis), SGLT2 inhibitors), opioids without laxatives, omitting VTE prophylaxis, failing to hold anticoagulants before procedures.
• Analgesia - WHO ladder - paracetamol (1 g four times daily; reduce to 500 mg–1 g with maximum 3 g/day if weight <50 kg or risk factors for hepatotoxicity), NSAID (with PPI if at risk; avoid in CKD, heart failure, peptic ulcer, late pregnancy), weak opioid, then strong opioid (oral morphine 2.5–5 mg PRN in opioid-naïve; regular laxative; antiemetic; lower doses in renal impairment - consider oxycodone or alfentanil per local guidance).
• Antiemetics - cyclizine (avoid in heart failure), ondansetron (QT prolongation; constipation), metoclopramide (avoid in Parkinson's and bowel obstruction; maximum 5 days; extrapyramidal effects in young people), haloperidol (palliative, avoid in Parkinson's), domperidone (cardiac risk).
• VTE prophylaxis (NICE NG89) - assess risk on admission; LMWH (e.g. enoxaparin 40 mg SC once daily, adjusted for weight and renal function) unless contraindicated (active bleeding, low platelets, recent stroke with haemorrhage); mechanical prophylaxis (anti-embolism stockings) for some surgical patients - not after stroke.

IV Fluid Prescribing

• NICE CG174 "5 Rs": Resuscitation, Routine maintenance, Replacement, Redistribution, Reassessment.
• Assess fluid status (history of intake and losses, observations, capillary refill, JVP, oedema, lung crackles, urine output, fluid balance charts, weight, U&E).
• Resuscitation - 500 mL crystalloid (0.9% sodium chloride or balanced solution - Hartmann's, Plasma-Lyte) over less than 15 minutes, reassess, repeat up to 2,000 mL then seek expert help (250 mL boluses in heart failure or frailty). Blood for haemorrhage.
• Routine maintenance (adults): 25–30 mL/kg/day of water, about 1 mmol/kg/day of sodium, potassium and chloride, and 50–100 g/day of glucose (to limit starvation ketosis). E.g. 70 kg adult - about 2 L/day: 1 L 0.18% sodium chloride in 4% glucose with 20 mmol KCl, twice a day (or per local guidance with balanced fluids). Consider 20–25 mL/kg/day in older or frail people, renal impairment, heart failure or malnutrition (refeeding risk). Do not exceed potassium 10 mmol/hour via a peripheral cannula on general wards (local policy).
• Replacement - add estimated ongoing losses (vomiting, NG aspirates - replace with sodium chloride and potassium; diarrhoea, fistulae, high-output stomas; fever; third-space losses).
• Redistribution - oedema with intravascular depletion (sepsis, hypoalbuminaemia, post-operative) - seek senior help.
• Reassess at least daily - clinical status, weights, fluid balance, U&E; switch to oral as soon as possible.
• Children use different regimens (Holliday–Segar - 100/50/20 mL/kg/day; isotonic fluids; NICE NG29) - hyponatraemia with hypotonic fluids is dangerous.

Insulin, Anticoagulants and High-risk Drugs

• Insulin - always write "units" in full; never omit basal insulin in type 1 diabetes (DKA risk); variable rate IV insulin infusion (VRIII) for those nil by mouth or with hyperglycaemia when unwell (with a glucose-containing fluid); fixed rate IVII (0.1 units/kg/hour) in DKA with continuation of long-acting insulin; hypoglycaemia treatment - if conscious and can swallow: 15–20 g fast-acting carbohydrate (e.g. 150–200 mL fruit juice or 4–5 glucose tablets), recheck after 10–15 minutes, repeat up to 3 times, then a long-acting carbohydrate; if unable to swallow - IV glucose (75–80 mL of 20% or 150–160 mL of 10% glucose over 10–15 minutes) or IM glucagon 1 mg.
• Warfarin - loading per local protocol; INR targets (2.5 for most VTE and AF; 3.5 for recurrent VTE on warfarin; mechanical valves by valve type); over-anticoagulation - stop warfarin; give vitamin K if INR >8 or bleeding; major bleeding - IV vitamin K 5–10 mg plus prothrombin complex concentrate (BSH); many interactions.
• DOACs - dose by indication, renal function (CrCl - Cockcroft–Gault), age and weight; reversal - idarucizumab (dabigatran), andexanet alfa or PCC (factor Xa inhibitors).
• Heparin - LMWH dosing by weight and renal function; unfractionated heparin infusion with APTT monitoring (renal failure, high bleeding risk); HIT (platelet fall 5–10 days after starting - 4Ts score, stop heparin, non-heparin anticoagulant).
• Other high-risk drugs - potassium (never IV bolus; concentrated KCl stored separately), opioids (naloxone for respiratory depression), methotrexate (weekly - "never events" for daily dosing), gentamicin (levels and renal function), vancomycin, digoxin, lithium, chemotherapy, insulin, anticoagulants - collectively the "A PINCH" high-alert medicines (anti-infectives, potassium and electrolytes, insulin, narcotics/opioids and sedatives, chemotherapy, heparin and anticoagulants).

ABCDE Assessment of the Acutely Unwell Patient

• Initial approach - check safety, gloves and apron, introduce yourself, ask "How are you?" (talking = patent airway, adequate perfusion of the brain); call for help early; get observations and monitoring attached; reassess after each intervention.
• A - Airway: look, listen, feel; signs of obstruction (stridor, gurgling, snoring, see-saw breathing, silence); manoeuvres (head tilt-chin lift, jaw thrust), suction, adjuncts (oropharyngeal, nasopharyngeal - avoid in basal skull fracture), call anaesthetics; anaphylaxis - IM adrenaline.
• B - Breathing: respiratory rate, SpO₂, chest expansion, tracheal position, percussion, auscultation, work of breathing; oxygen (15 L/min via non-rebreathe mask if critically ill, then titrate to target 94–98%, or 88–92% if at risk of hypercapnia - BTS); ABG; CXR; treat - nebulisers (bronchospasm), needle decompression (tension pneumothorax).
• C - Circulation: pulse (rate, rhythm, volume), BP, capillary refill, JVP, heart sounds, peripheral temperature, urine output (catheter if needed); two large-bore cannulas; bloods (FBC, U&E, LFTs, clotting, group and save/crossmatch, lactate, cultures, glucose); fluid bolus (500 mL crystalloid over <15 minutes); ECG and monitor; treat the cause (sepsis - antibiotics within 1 hour; haemorrhage - blood and source control; arrhythmia).
• D - Disability: ACVPU or GCS, pupils, blood glucose ("don't ever forget glucose"), temperature (E), drug chart (opioids, sedatives, insulin), seizure activity, focal neurology; treat hypoglycaemia; naloxone for opioid toxicity; airway protection if GCS ≤8.
• E - Exposure: examine the whole body with dignity - rashes (non-blanching), bleeding, wounds, swelling, calves (DVT), abdomen (peritonism, distension), surgical sites, lines, catheters; temperature.
• Then - review notes, charts and results; SBAR to a senior; document; decide on escalation (critical care, ceiling of care, DNACPR/ReSPECT); reassess.
• Sepsis Six (within 1 hour) - give oxygen (target saturations), take blood cultures, give IV antibiotics, give IV fluids, measure lactate (and FBC), monitor urine output.

Cardiac Arrest and Peri-arrest Stations

• Recognise arrest - unresponsive, not breathing normally (agonal gasps are not normal breathing), no signs of life; call the cardiac arrest team (2222 in most UK hospitals), get the defibrillator.
• Start CPR - 30 compressions : 2 ventilations; compressions at 100–120 per minute, depth 5–6 cm, full recoil, minimise interruptions; change compressor every 2 minutes.
• Attach the defibrillator (pads - right infraclavicular and left mid-axillary V6 position) and assess rhythm:
  • Shockable (VF/pulseless VT) - shock (150–200 J biphasic initially per device), resume CPR immediately for 2 minutes; adrenaline 1 mg IV and amiodarone 300 mg IV after the third shock; further adrenaline every 3–5 minutes (alternate loops); amiodarone 150 mg after the fifth shock.
  • Non-shockable (PEA/asystole) - CPR; adrenaline 1 mg IV as soon as access is obtained, then every 3–5 minutes.
• Reversible causes - 4 Hs and 4 Ts: Hypoxia, Hypovolaemia, Hypo/hyperkalaemia and other metabolic (hypoglycaemia, hypocalcaemia, acidaemia), Hypothermia/hyperthermia; Thrombosis (coronary or pulmonary), Tension pneumothorax, Tamponade (cardiac), Toxins. Point-of-care ultrasound by trained operators.
• Airway - bag-valve-mask with adjuncts, supraglottic airway (i-gel) or tracheal intubation by skilled operator; waveform capnography (confirms tube placement, monitors CPR quality, ROSC - sudden rise in ETCO₂).
• ROSC - ABCDE, aim SpO₂ 94–98%, normocapnia, 12-lead ECG (PCI if STEMI), avoid hypotension (MAP ≥65 mmHg), temperature control (prevent fever), glucose control, treat the cause, ICU.
• Peri-arrest arrhythmias (Resuscitation Council UK 2021): adverse features - shock, syncope, myocardial ischaemia, severe heart failure → synchronised DC cardioversion (up to 3 attempts) for tachycardias, then amiodarone 300 mg over 10–20 minutes; stable narrow-complex regular tachycardia - vagal manoeuvres (modified Valsalva), then adenosine 6 mg, 12 mg, 18 mg rapid IV bolus (avoid in asthma; warn the patient about a transient sense of doom); bradycardia with adverse features - atropine 500 micrograms IV, repeat to a maximum of 3 mg, then pacing (transcutaneous), isoprenaline or adrenaline infusion.
• Human factors - clear team leader, closed-loop communication, allocated roles, situational awareness, debrief afterwards.

Common Emergency Simulations

Emergency	Key immediate actions
Anaphylaxis	ABCDE, remove trigger, IM adrenaline 500 micrograms (0.5 mL of 1 mg/mL) anterolateral thigh, repeat after 5 minutes if no improvement; high-flow oxygen, IV fluids; after two doses with no improvement - refractory anaphylaxis (adrenaline infusion, critical care); tryptase; antihistamines are not first line (RCUK 2021)
Acute severe asthma	Oxygen (94–98%), salbutamol 5 mg nebulised (back-to-back if severe), ipratropium 500 micrograms, prednisolone 40–50 mg or hydrocortisone 100 mg IV, IV magnesium sulphate 2 g over 20 minutes if life-threatening or not responding; ABG if SpO₂ <92% (normal or high PaCO₂ is life-threatening); ICU
COPD exacerbation	Controlled oxygen 88–92% (Venturi), nebulised bronchodilators, steroids, antibiotics if purulent; ABG; NIV for respiratory acidosis
Sepsis	Sepsis Six within 1 hour; source control; escalate if lactate >4 or hypotension unresponsive to fluids (vasopressors)
Upper GI bleed	ABCDE, two large-bore cannulas, crossmatch, Glasgow–Blatchford score, transfuse (restrictive Hb 70 g/L, 80 g/L in cardiac disease), stop anticoagulants and reverse, terlipressin and antibiotics if variceal, endoscopy within 24 hours (immediately after resuscitation if unstable)
DKA	Fluids (0.9% saline 1 L over 1 hour if SBP >90), fixed-rate insulin 0.1 units/kg/hour, continue long-acting insulin, potassium replacement per levels, add 10% glucose when glucose <14 mmol/L, hourly monitoring (JBDS)
Hypoglycaemia	Oral carbohydrate if able; IV glucose (75–80 mL of 20% over 10–15 minutes) or IM glucagon 1 mg; recheck and find the cause
Hyperkalaemia (≥6.5 or ECG changes)	IV calcium gluconate 10% 30 mL (or calcium chloride) over 5–10 minutes to stabilise the myocardium; insulin 10 units in 25 g glucose; salbutamol nebulised 10–20 mg; treat the cause, stop offending drugs; dialysis if refractory (UK Kidney Association)
Status epilepticus	ABCDE, glucose, benzodiazepine at 5 minutes (IV lorazepam 4 mg, or buccal midazolam 10 mg / rectal diazepam 10 mg if no access), repeat once after 5–10 minutes, then levetiracetam 60 mg/kg (max 4.5 g), phenytoin or valproate; anaesthetics/ICU if continuing at 45 minutes
Opioid toxicity	Airway, oxygen, naloxone 400 micrograms IV/IM (titrate in small increments in palliative or dependent patients), repeat as needed; infusion for long-acting opioids
Tension pneumothorax	Immediate needle decompression or open thoracostomy (2nd ICS mid-clavicular or 4th–5th ICS mid-axillary line), then chest drain
Acute coronary syndrome	ECG within 10 minutes, aspirin 300 mg, GTN, morphine and antiemetic if needed, oxygen only if hypoxic, primary PCI for STEMI within 120 minutes of diagnosis (thrombolysis if not achievable), second antiplatelet per protocol
Stroke	ABCDE, glucose, FAST/ROSIER, urgent non-contrast CT ± CT angiography, thrombolysis within 4.5 hours of onset and thrombectomy up to 24 hours in selected patients; BP management per protocol
Meningitis/meningococcal sepsis	IV ceftriaxone 2 g immediately (do not delay for LP or CT); add amoxicillin if over 60 or immunocompromised; dexamethasone (before or with the first antibiotic dose if bacterial meningitis suspected); notify

At a Glance

Station	Remember
Any procedure	ID, consent, allergies, ANTT, sharps at point of use, label at bedside, document
Cannula size	18G/16G for fluids and blood; 20G for drugs
Catheter	Inflate only when urine flows; replace the foreskin
NG tube	pH ≤5.5 or CXR - never whoosh test
ECG leads	Red right arm, yellow left arm, green left leg, black right leg; V1–V6 positions
NEWS2	≥5 urgent review; ≥7 emergency
Maintenance fluids	25–30 mL/kg/day water; 1 mmol/kg/day Na, K, Cl; 50–100 g glucose
Resuscitation fluids	500 mL over <15 min, reassess
Anaphylaxis	IM adrenaline 500 micrograms, repeat after 5 min
Arrest	30:2; adrenaline every 3–5 min; amiodarone after 3rd shock
Hyperkalaemia	Calcium gluconate, insulin–glucose, salbutamol

Worked Example Stations

• Prescribing - "Mr Green, 78 kg, has community-acquired pneumonia (CURB-65 = 2). He is allergic to penicillin (anaphylaxis). Prescribe appropriate treatment." Check allergy documented; follow local guidance - e.g. clarithromycin 500 mg twice daily (oral if tolerated) or doxycycline; for moderate severity NICE NG138 suggests amoxicillin (adding clarithromycin if atypical infection is suspected); with penicillin allergy - clarithromycin or doxycycline (levofloxacin for high severity, with microbiology advice); write duration (5 days) and review date; VTE prophylaxis; paracetamol PRN; oxygen prescription with target saturations; check interactions (statins with clarithromycin - suspend simvastatin).
• Fluids - "Mrs Ahmed, 60 kg, nil by mouth after surgery, normal U&E, euvolaemic. Prescribe 24 hours of maintenance fluids." Water 25–30 mL/kg/day = 1.5–1.8 L; sodium/potassium about 60 mmol each; glucose 50–100 g. Example: 0.18% sodium chloride/4% glucose with 20 mmol KCl 1 L over 12 hours, then 0.18% sodium chloride/4% glucose with 20 mmol KCl 500 mL over 8 hours (adjust per local guidance), check U&E daily, review oral intake.
• Acute - "You are called to see a 68-year-old man on the surgical ward: HR 118, BP 86/50, RR 26, SpO₂ 93% on air, temperature 38.9°C, confused (new). He had a bowel resection 3 days ago." NEWS2 high → call senior/outreach early; ABCDE; oxygen; two cannulas; bloods including cultures and lactate; IV fluid bolus 500 mL; IV broad-spectrum antibiotics within 1 hour per local post-operative abdominal sepsis guidance; catheter and urine output; examine the abdomen and wound (anastomotic leak); urgent CT; escalate to the surgical registrar using SBAR; consider critical care.

Exam-style Scenarios

• Scenario. On a mannequin, you insert a male catheter. Urine does not flow and the patient reports pain when you start inflating the balloon. What do you do?
  Answer: Stop inflating and deflate the balloon immediately - it is probably in the urethra (risk of urethral trauma). Check the catheter has been advanced fully to the hilt; ensure lubrication/anaesthetic gel; if still no urine, consider a bladder scan (is the bladder full?), and if difficulty persists, seek senior or urology help rather than forcing it.
• Scenario. A drug chart shows "Methotrexate 10 mg once daily" for a patient with rheumatoid arthritis. What do you do?
  Answer: This is a dangerous error - methotrexate for RA is given once weekly. Do not administer; correct the prescription to once weekly on a specified day with folic acid on another day; inform the prescriber and the patient's team, check whether any extra doses have been given (check FBC, LFTs, renal function; folinic acid rescue if toxicity), and report via the incident system.
• Scenario. In a simulated arrest, the monitor shows VF after the third shock. What drugs are given, and when?
  Answer: Immediately resume CPR after the third shock and give adrenaline 1 mg IV and amiodarone 300 mg IV. Continue 2-minute cycles; adrenaline every 3–5 minutes (every other cycle); amiodarone 150 mg after the fifth shock; consider reversible causes (4 Hs and 4 Ts).

Key Points

• Every procedure: identify, consent, allergies, aseptic technique, safe sharps, label, document.
• Know the GMC practical procedures list and practise each until automatic.
• Prescribing: check weight, allergies, renal function and interactions; write clearly with durations.
• Fluids: 5 Rs; 500 mL bolus for resuscitation; 25–30 mL/kg/day maintenance.
• ABCDE: call for help early, treat as you find, reassess, SBAR.
• Learn the ALS algorithm, peri-arrest drug doses and emergency regimens exactly.

Guidelines and Further Reading

• GMC: MLA requirements - practical skills and procedures
• Resuscitation Council UK: Adult advanced life support guidelines (2021); Emergency treatment of anaphylaxis (2021)
• NICE CG174: Intravenous fluid therapy in adults in hospital; NICE NG29: IV fluid therapy in children
• Royal College of Physicians: National Early Warning Score (NEWS) 2
• Joint British Diabetes Societies: Management of DKA in adults; hospital hypoglycaemia guidelines
• NHS England: Never Events list; NPSA alert on NG tube placement checks
• Prescribing Safety Assessment (British Pharmacological Society / Medical Schools Council)