Examiner:

• "Mr. John Doe, a 65-year-old male with a history of end-stage renal disease on hemodialysis via a left AV fistula, presents to the emergency department with severe abdominal pain, fever, and hypotension. His vitals on arrival are BP 80/50 mmHg, HR 110 bpm, and temperature 39.0°C. He has diffuse abdominal tenderness with guarding. What are your initial steps in managing this patient?"

Examinee:

• "I would begin by assessing and stabilizing the patient's airway, breathing, and circulation. Given his hemodynamic instability, I would start with two large-bore IV lines and administer IV fluids. As I am concerned about abdominal sepsis based on his presentation, I would get blood cultures and start broad-spectrum antibiotics. I would also order labs including a complete blood count, electrolytes, renal function tests, and a lactic acid level. Additionally, I would obtain a CT scan of the abdomen and pelvis to evaluate for intra-abdominal pathology."

Examiner:

• "The patient is found to have perforated diverticulitis with free air and fluid in the abdomen. Despite aggressive fluid resuscitation, his blood pressure remains low at 70/40 mmHg. Peripheral IV access is difficult, and his left AV fistula limits options for additional access. What is your next step?"

Examinee:

• "Given the patient's hemodynamic instability and poor peripheral access, I would proceed with placing a central venous catheter. Since he has a left AV fistula, I would avoid using the left arm and subclavian veins, and I would opt for an ultrasound-guided internal jugular (IJ) central line on the right side to provide reliable access for vasopressors and further fluid resuscitation."

Examiner:

• "You decide to place an ultrasound-guided right IJ central line. Can you describe the steps you would take to perform this procedure?"

Examinee:

• "I would first obtain informed consent if possible, then gather all necessary equipment, including the central line kit and ultrasound machine. I would position the patient in Trendelenburg to distend the IJ vein and turn his head slightly to the left. After identifying the IJ vein and carotid artery with the ultrasound, I would prepare the skin with antiseptic solution and drape the area. Using the ultrasound in the transverse view, I would insert the needle into the IJ vein, confirming placement with blood return. I would then advance a guidewire through the needle, remove the needle, and make a small skin incision. Next, I would pass the dilator over the guidewire to dilate the tract, followed by threading the central venous catheter over the guidewire into the vein. Finally, I would remove the guidewire, aspirate blood from all ports, flush with saline, and secure the catheter with sutures and a sterile dressing."

Examiner:

• "During the procedure, you notice that the guidewire does not advance smoothly and the patient experiences increasing neck pain. What could be the cause and how would you proceed?"

Examinee:

• "The difficulty in advancing the guidewire and the patient's increasing neck pain could indicate that the guidewire has encountered resistance or is in a false passage. I would stop advancing the guidewire, withdraw it, and re-evaluate the position of the needle tip with the ultrasound. If necessary, I would reposition the needle in the IJ vein under ultrasound guidance and attempt to pass the guidewire again. Ensuring that the needle is correctly positioned in the vein before advancing the guidewire is crucial."

Examiner:

• "You successfully place the central line, and the patient's blood pressure improves to 95/60 mmHg with fluid resuscitation and vasopressor support. What complications should you monitor for following IJ central line placement?"

Examinee:

• "Following IJ central line placement, I would monitor for complications such as pneumothorax, hemothorax, arterial puncture, infection, thrombosis, and catheter malposition. I would obtain a chest X-ray to confirm the position of the catheter tip and to check for pneumothorax or hemothorax. I would also monitor the insertion site for signs of infection and ensure that the catheter is functioning properly by aspirating blood and flushing each port."

Examiner:

• "After several days, the patient develops swelling and erythema around the central line insertion site, and new blood cultures are positive for methicillin-resistant Staphylococcus aureus (MRSA). What is your management plan?"

Examinee:

• "The development of swelling and erythema around the insertion site with positive MRSA cultures indicates a catheter-related infection. I would remove the central line immediately and replace it with a new femoral central line if still needing central access to avoid stenosis of the central veins that would affect his AV fistula. I would start the patient on appropriate antibiotics based on sensitivity results, such as vancomycin for MRSA coverage. I would continue to monitor the patient closely for signs of systemic infection or sepsis and ensure proper wound care for the insertion site."

Examiner:

• "Ms. Jane Smith, a 45-year-old female with no significant past medical history, presents to the emergency department after a motor vehicle collision with severe abdominal and pelvic injuries. She is currently protecting her airway and has bilateral breath sounds. She is hypotensive with a blood pressure of 70/40 mmHg, tachycardic with a heart rate of 130 bpm, and has weak peripheral pulses. Multiple attempts at peripheral IV access have failed, and she requires rapid fluid resuscitation and massive transfusion. What are your initial steps in managing this patient?"

Examinee:

• "My initial steps would involve performing a rapid primary survey following the ATLS ABCDE approach, focusing on stabilizing the patient's airway, breathing, and circulation. Given her hemodynamic instability and failure to obtain peripheral IV access, I would establish intraosseous (IO) access in both humeri to start fluid resuscitation and administer medications. I would also prepare for central venous access due to the anticipated need for high-volume resuscitation and transfusion."

Examiner:

• "Despite aggressive resuscitation through bilateral humeral IO access, the patient's blood pressure remains low at 70/40 mmHg."

Examinee:

• "Given the need for rapid and reliable central venous access, I would choose to place a landmark-guided subclavian central line. The subclavian vein provides a large, stable access point for resuscitation and can be accessed quickly in trauma situations and keeps the head of the bed clear for potential airway access and interventions."

Examiner:

• "Can you describe the anatomical landmarks and technique for placing a left subclavian central line?"

Examinee:

• "For a landmark-guided subclavian central line, the key anatomical landmarks are the deltopectoral groove, the clavicle and the junction of its middle and medial thirds, and the sternal notch. If time permitted, I would prepare and drape the area using antiseptic solution. Then, I would insert a 22-gauge finder needle just below the clavicle in the deltopectoral groove and parallel to the floor, directing it towards the suprasternal notch under the junction of the middle and medial thirds of the clavicle while aspirating for venous blood. Once venous blood is aspirated, I would advance a guidewire through the needle into the vein. After removing the finder needle, I would use a scalpel to make a small incision at the skin entry point and advance a dilator over the guidewire to dilate the tract. I would then thread the central venous catheter over the guidewire and advance it into the vein, remove the guidewire, and confirm venous placement by aspirating blood from each port and flushing with saline. Finally, I would secure the catheter with sutures, apply a sterile dressing, and obtain a chest X-ray to confirm the position of the catheter tip and check for complications such as pneumothorax."

Examiner:

• "During the procedure, you encounter difficulty advancing the guidewire and the patient starts experiencing shortness of breath and decreased breath sounds on the right side. What is your differential diagnosis and how would you manage this situation?"

Examinee:

• "The difficulty advancing the guidewire and the patient's new symptoms suggest possible complications, including pneumothorax, hemothorax, or arterial puncture. To manage this situation, I would immediately stop advancing the guidewire and perform a rapid clinical assessment, including auscultation and checking for signs of tension pneumothorax. I would obtain an urgent chest X-ray to confirm the diagnosis of pneumothorax or hemothorax. If the patient is in respiratory distress and I suspect a tension pneumothorax, I would perform finger thoracostomy decompression followed by placement of a chest tube."

Examiner:

• "The chest X-ray confirms a right-sided pneumothorax. You place a chest tube and the patient's respiratory status stabilizes. Can you describe the steps you take to place the chest tube?"

Examinee:

• "To place the chest tube, I would first identify the appropriate insertion site, which is the fifth intercostal space, anterior to the mid-axillary line. I would use the nipple in men or the inframammary line in women as a landmark. After positioning the patient with the arm raised above the head on the affected side to expose the insertion site, I would prepare and drape the area using an antiseptic solution. Next, I would make a horizontal incision over the rib at the insertion site and use blunt dissection with a Kelly clamp to create a tract through the intercostal muscles and into the pleural space, ensuring I went just above the rib to avoid the neurovascular bundle. Once I entered the pleural space, I listen for a rush of air and look for blood. I would then insert my finger into the tract to confirm entry into the pleural cavity and clear any adhesions, followed by advancing the chest tube through the tract into the pleural space, directing it posteriorly and superiorly. After securing the tube in place with sutures and applying a sterile dressing, I would connect it to an underwater seal drainage system and confirm placement with a chest X-ray."