Candidate Score
number
MET Call Oncology
Stem
You are the ICU consultant on call overnight at a tertiary hospital. You
receive a call from your registrar, who is attending a MET call on the ward.
They inform you that there is a 28 year old male on the oncology ward who
has been discovered to have a GCS of 3 by the nurse performing routine
observations. He is breathing spontaneously with snoring respirations and
has a HR of 60 bpm and BP of 150/80 mmHg.
The history they have so far is that he was admitted 3 days ago with acute
confusion. On CT head on admission he was discovered to have multiple
haemorrhagic intracerebral mass lesions, including a 40 mm x 40 mm
mass in the left frontal lobe. A subsequent CT chest/abdo/pelvis revealed
multiple lesions within the lungs, liver and spleen.
1. Describe how you would respond to your registrar on the phone?
□ Determines how comfortable the registrar is managing the
situation (registrar is junior and not comfortable)
□ Appreciates urgency of situation and that ultimately patient
requires airway management, urgent CT head, neurosurgical
review, transfer to ICU
□ Provides some temporising advice to registrar while coming in
(basic airway/breathing/circulation management, check glucose,
determine whether there is on-site support for registrar in
meantime e.g. anaesthesia)
Prompt: Midway through your conversation, the patient begins to have a tonic
clonic seizure. Your registrar says that they feel out of their depth and
requests that you attend urgently to help them, and you do so.
Excellent Good pass Pass Fail Bad fail Abysmal
15 12 8 5 2 0
When you arrive at the patient’s bedside you find he has a GCS of 3. He
has a fixed and dilated left pupil.
2. Describe your immediate management?
□ Identifies patient needs urgent CT head but requires airway
management prior to this (airway protection, ICP management)
□ Describes safe intubation with reference to
preparation/optimization which may include
□ Use of checklist
□ Ensure adequate assistance available
□ Monitoring
□ States airway plan with back-up plan
□ Preoxygenation
□ RSI given fasting status unclear
□ Notes raised ICP and makes sensible drug plan with goals:
Avoidance of sympathetic stimulation with
laryngoscopy
Avoidance of hypotension with induction
□ Capnography to confirm ETT placement
□ Describes ICP management
□ Head up and neutral position, normoxia, normocapnia,
osmotherapy, maintain MAP (target 80mmHg)
□ Sedation, analgesia, paralysis
□ Urgent neurosurgical consult
Excellent Good pass Pass Fail Bad fail Abysmal
20 15 10 7 3 0
3. What are the principles of safely transporting this patient to the CT
scanner?
□ Maintain the same standard of care as the patient is currently
receiving (in terms of monitoring and expertise)
□ Staff – at least a nurse, orderly and medical practitioner with
adequate skills for transporting a ventilated patient
□ Monitoring – pulse ox, capnography, ECG, NIBP, alarms for
breathing system disconnection or ventilator failure
□ Drugs – sedatives, muscle relaxant, vasopressor
□ Equipment – oxygen, suction, airway equipment
Excellent Good pass Pass Fail Bad fail Abysmal
10 7 5 3 1 0
A CT head is performed which demonstrates the intracranial lesions as
described. There is 13mm of midline shift and left uncal herniation.
4. What are you management priorities now?
□ Urgent neurosurgical consult
□ Transfer to theatre
Excellent Good pass Pass Fail Bad fail Abysmal
5 4 3 2 1 0
A category 1 craniotomy is booked. However, the neurosurgeon is
coming in from home and you decide to transport the patient back to
ICU to await theatre. During this time, you notice that the patient is
becoming progressively tachycardic and hypotensive, with a HR up to
170bpm and BP of 80/40 on escalating doses of metaraminol, then
noradrenaline.
5. What are your differentials for this haemodynamic disturbance, and how
would you identify the cause?
□ Hypovolaemic - blood loss
□ Cardiogenic – SVT, Takotsubo
□ Vasoplegic - Effect of drugs used for sedation; drug error;
anaphylaxis; post foramen magnum herniation – vasomotor centre
damage, catecholamine depletion and loss of sympathetic tone
□ Obstructive – SVC obstruction, tension pneumothorax following
intubation/mechanical ventilation
Bad
Excellent Good pass Pass Fail Abysmal
fail
10 7 5 3 0
1
Identifying the cause
□ Clinical examination
□ Warm and vasodilated vs cool/shut down
□ Evidence of bleeding (abdominal distension)
□ Evidence of coning
□ Skin rash, bronchospasm (anaphylaxis)
□ Review infusions for drug errors
□ Investigations
□ ECG – SVT?
□ eFAST scan at bedside
□ Free fluid in abdomen
□ Lung sliding
□ Echo
□ CXR
□ Blood gas
Bad
Excellent Good pass Pass Fail Abysmal
fail
5 4 3 2 0
1
Thankfully, the anaesthetist appears to wheel the patient off to theatre,
where he undergoes a craniotomy and resection of frontal lobe tumour.
Due to persistent hypotension, he undergoes a CT C/A/P immediately
post-op which reveals extensive active haemorrhage from a splenic
lesion.
He is taken directly from CT for splenic artery embolization.
On arrival back in ICU, you see that in total he has received 6 litres of
crystalloid, 8 units of PRBC, and 2 units of FFP.
7. What is your assessment and management of this patient’s
coagulation status?
□ Patient has received massive unbalanced transfusion
□ Send coagulation studies and/or TEG/ROTEM and use results to
guide further product replacement (if indicated)
□ Assess for ongoing bleeding
□ Examine for evidence of DIC clinically
□ Ensure normothermia, ionized calcium >1, aim normal pH
Bad
Excellent Good pass Pass Fail Abysmal
fail
10 7 5 3 0
1
What is your plan for this patient for the next 12 hours?
8. What is your assessment and management of this patient’s
coagulation status?
□ Patient should be desedated and assessed clinically
□ Discuss with neurosurgery whether post-craniotomy imaging
required today
□ Assess for any evidence of ongoing bleeding
□ Correct coagulopathy
□ Meet with family
Bad
Excellent Good pass Pass Fail Abysmal
fail
10 7 5 3 0
1
Gestalt Marks
Bad
Excellent Good pass Pass Fail Abysmal
fail
10 7 5 3 0
1
Preliminary total /100
Divide preliminary total by 2 if any of the following occur:
Doesn’t check whether the registrar needs help /wants
them to attend.
Doesn’t prioritise securing airway prior to CT
Doesn’t mention ICP management without direct
prompting
Doesn’t identify patient has received a massive
(unbalanced) transfusion and may have a coagulopathy
as a result
/
Final total
100
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