Sample · ACRRM
Ute rollover with haemorrhagic shock: stabilising while retrieval is three hours away
Viva · Emergency and retrieval · 20 marks. Decide what you would do, then compare with the marking guide and model performance. In the app you run it against the clock, with a colleague or an AI role-player, and it comes back marked.
You are the only doctor on call at Mulga Springs Hospital (12 beds, two nurses overnight, X-ray, point-of-care blood gas, two units of O-negative red cells, no CT, no surgeon). At 2300 a volunteer ambulance brings in Jack, a 34-year-old station hand whose ute rolled on a dirt road 80 km out of town about 90 minutes ago. He was found walking around but is now pale and breathless, complaining of right chest and pelvic pain. The examiner will ask you three questions and give you further information as the scenario unfolds.
- Describe your immediate assessment and management in the first 15 minutes.
- Manage the deterioration the examiner describes while you wait for retrieval.
- Hand over to the retrieval team and look after the people around the patient.
Show the marking guide and model performance
- Problem definition: identifies haemorrhagic shock (class III) from right haemothorax with probable pelvic and liver injury in a patient beyond local definitive care, in a time-critical retrieval setting (3)
- Structured primary survey (catastrophic haemorrhage, airway with cervical spine care, breathing, circulation, disability, exposure) with simultaneous interventions, delegating tasks to the nurses and ambulance officer (2)
- Breathing: high-flow oxygen; recognises large haemothorax and inserts a large-bore right intercostal catheter (or states readiness to decompress if tension develops) (2)
- Circulation: two large-bore IV or intraosseous access; pelvic binder centred over the greater trochanters; tranexamic acid 1 g IV over 10 minutes within 3 hours of injury then 1 g over 8 hours; early O-negative red cells (3)
- Permissive hypotension (target systolic 80 to 90 mmHg or palpable radial pulse, as no head injury) and minimal crystalloid; actively warms (warm fluids, blankets, warm room) to avoid the lethal triad; considers calcium with transfusion (2)
- Early telehealth conference with the retrieval consultant; asks for blood products and fibrinogen on the aircraft; analgesia titrated (e.g. fentanyl 25 to 50 microgram IV increments or ketamine 0.1 to 0.3 mg/kg IV) (2)
- Deterioration: recognises ongoing haemorrhage (more than 1,500 mL initial or more than 200 mL per hour) as an indication for surgery that cannot happen locally; escalates priority, reassesses, avoids intubating a shocked patient unless needed, uses remaining blood (2)
- Recognises falling GCS as hypoperfusion or hypothermia first, rechecks glucose and gas, reassesses ABCDE rather than anchoring on head injury (1)
- Structured handover (e.g. MIST: mechanism, injuries, signs, treatment, with times, totals in and out, drugs given) (1)
- Communication/professionalism: speaks with partner honestly and kindly, keeps her informed; debriefs the junior nurse and staff; documents contemporaneously with times; considers incident notification if any adverse event (2)
"This is a polytrauma patient in haemorrhagic shock, likely class three, with a right haemothorax and a possible pelvic and liver injury, and we're three hours from definitive care. I'd call the team together: one nurse on monitoring and access, the night supervisor scribing and on the phone, the ambulance officer helping me.
I'd do a primary survey and fix things as I find them. No external catastrophic bleeding. Airway is patent; I'd keep his neck in line given the mechanism. Breathing: high-flow oxygen through a non-rebreather. The dull, quiet right base with ultrasound confirming a large haemothorax means a right intercostal catheter, size 28 French or larger, in the fifth intercostal space just anterior to mid-axillary line, with local anaesthetic and analgesia. Circulation: two large-bore cannulas, intraosseous if I can't get them quickly; a pelvic binder over the greater trochanters; tranexamic acid 1 gram IV over 10 minutes now, as we're within 3 hours of injury, then 1 gram over 8 hours; and start the O-negative. I'd aim for a systolic of 80 to 90 because there's no head injury, and avoid crystalloid. Warm everything: fluids, blankets, room. Disability: GCS 15, glucose fine. Exposure: log roll briefly, then keep him covered.
I'd speak to the retrieval consultant on video early and ask them to bring red cells, plasma if possible and fibrinogen.
At 30 minutes: 900 mL out of the drain and 250 more since means he is still bleeding, and that's a surgical problem I can't fix here. I'd tell the retrieval consultant, ask whether a faster asset is available, give the second unit, give calcium, keep warming and titrate fentanyl in small doses. I would avoid intubating him while he's this shocked unless his airway or breathing forced it.
At 75 minutes: the confusion is most likely hypoperfusion and cold, so I'd reassess ABCDE, recheck gas and glucose.
For handover I'd use MIST with times and totals: two units, tranexamic acid times, drain output. Then I'd sit with Mia somewhere private, explain he is seriously injured and the plan, and later debrief the nurses and write my notes with times."
Where candidates lose marks here
- Defaulting to "transfer" without initial stabilisation; the retrieval delay is the point of the scenario.
- Giving tranexamic acid without dose or the 3-hour window, or giving litres of crystalloid.
- Placing the pelvic binder over the iliac crests rather than the greater trochanters.
- Forgetting hypothermia and calcium in a patient receiving blood.
- Ignoring the partner and the shaken junior nurse in the communication domain.
Original content written for Fellowship Ready, for exam preparation only, not clinical advice. Not affiliated with the Australian College of Rural and Remote Medicine.