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Table of Contents

Subject Page

Teaching station structure 3

Epipen teaching 6

Urine dipstick teaching 11

Subcutaneous injection teaching 15

ECG teaching 20

Basic life support teaching 25

Speculum examination 37

Inguinoscrotal examination 46

Cancer pathway 53

Toddler milestones 57

Informed consent 61

Vaccination teaching 67

Vaccination refusal 72

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Teaching Station Structure

Smile Please! It is a happy station
Introduction
- Do not address yourself as Dr. Say; ‘I am X, One of your FY2 colleagues here'.
- ID check: confirm the student's name and year.
- Build rapport: The rapport must be based on a professional relationship and
shouldn't be overly friendly or cold emotionless.
- How’s work/ Study/ Rotations/ Encourage/ Wish Luck for exams. (A
maximum of three questions).
- “How is your study ongoing?”
- “How are you liking the ward so far?”
- “How is your rotation ongoing?”
- “Are there any exams coming up soon?”
- “Well, I wish you the best of luck for your exam.”
- “Are you settling well in the ward?”
- “Have you seen any interesting cases here?”
- Acknowledge: ‘I appreciate that you came to me to learn about XYZ. You
are going to be a great Dr one day’.
- Safety net in case you run out of time:
- ‘I might get bleeped in the middle of this conversation so please do
bear with me and I will arrange another session again if that
happens’.
- ‘If I cannot nish this in one go, please bear with me. I am happy to
arrange another session for you’.
- ‘I will also give you an NHS link to this topic so’ that you can read it
again at home. What do you think?’.

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- Open invitation:
- ‘Please come back if you want to learn again’.
- Main concern: if it’s a patient or relative coming to learn something.
- Rephrase the stem if what the student wishes to learn has already been
written in the stem, don’t start with ‘how can I help you?’.
- Assess Knowledge (4 W) :
- What do you know about it?
- What do you want to know?
- Why do you want to know?
- When and why do we do it?
- +/- Patient Safety:
- PMH/ Drug/Allergies/Jabs/Social.
- Or if the colleague brings any teaching material ask, where did you get
this sample from/ how is that pt. doing/ did you take consent, etc.
- Teach the station:
- Only teach what they requested
- Do and show: Teach procedure or examination.

- Don’t forget to take the colleague with you to the mannequin or

anywhere you go to teach them.
- Always remember that anything provided inside the cubicle is for a
reason and for you to use it while showing the colleague.

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Golden TIPs that you should apply at all stations

- Don’t ever teach wrong medical information or try to fabricate or invent
information.
- Don’t over-teach or under-teach.
- Don’t ask complicated questions that you wouldn’t be able to answer.
- Always assess understanding, and ask the student if you are going fast or not,
or if they want you to repeat anything.
- Always involve the student in the teaching.
- Some of the stations that will be explained here come in the exam as
teaching and as a combined examination, so always be ready to tackle them
with both approaches.
- Always have your way of teaching, and avoid repeating xed phrases as
much as you can.
- You can use medical terms as you are dealing with medical professionals, but
at the same time try to simplify things as much as you can.

IPS in Teaching
Check understanding:
- pick on the non-verbal cues.
- It is never about knowledge, It is about the way you teach.
- Eye contact, nuances of the voice, body movements, body orientation,
facial expressions.

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Epipen
Scenario
Where You Are:
You are an FY2 doctor working in GP surgery.
Who the Patient is:
Jason Winslow 8-year-old boy was admitted to the hospital with anaphylaxis
after ingesting peanuts one week back. This is the 2nd time he developed
anaphylaxis. He was treated that time and was prescribed epipen. His mother
Becca Winslow has questions about how to use the EpiPen.
Special Note:
There is an EpiPen Trainer on the table inside the Cubicle.
What you must do:
Please talk to the mother and teach her how to use the EpiPen.

Mother’s questions:
- What if Jason doesn’t respond to it first time, should I use it again?
- What is I use the EpiPen and it’s not anaphylaxis?
- Shall I need to call an ambulance if he becomes alright after the shot?

Approach
- Smile
- Introduce yourself and explain your role.
- ID check of the mother and her son: ‘I can see from my notes that you came
for your son Jason Winslow. Is that correct? It’s nice to meet you, Becca.
Could you con rm Jason’s age for me, please?’
- Build Rapport: ‘How is he doing now? / How was the hospital stay? /How
was the care by the doctors? … etc
- Main concern: She wants to learn about EpiPen. Here you should praise her
for being a good mother.
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- Assess her knowledge: Child, Attack and Epipen

- Child: When was he diagnosed with allergy. What is he allergic to; food/
medications?
- Attack: Recap what happened and what they did. What symptoms he
had? For how long did it last? What was your reaction, who has been
around him? what they noticed about him?
- EpiPen: When was the EpiPen prescribed for him? Or did you use it
before / do you know how to use it …? What if she tried to use the pen but
could not remember how?
- Manage the anxiety of the mother and encourage her:
- Tell the mother that what she did was brave and that it saved her son’s
life ‘Mrs. Winslow, I understand that being in this kind of situation
could have been unimaginably hard for you. But you know that you
are doing that to save your Jason’s life. Please try to take your breath,
calm down, and do it.’
- Encourage her to gather strength next time and calm down when trying
to use the EpiPen.
- Check / Safety Net:
- Check that she knows what she might observe or look for symptoms of
allergy.
- Do you know when you might have to use the EpiPen? /Do you have
any idea of the signs of a severe allergic reaction?

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Teach
Explain the Pen:
- It’s a device that contains a very important medicine ( Adrenaline ) to treat
anaphylactic attacks.
- It has two ends; blue and orange.
- The ORANGE end contains the needle. Needle is covered and retractable so
do not worry about getting hurt.
- Check expiration date and exchange them at GP if expired or used.
- Check this small window it contains the drug and watch for any changes as
sunlight can affect the medication inside. That is why it is very important not
to keep it in extremities of temperature.
How to use it:
- Hold it Like a grip; BLUE to the sky, ORANGE to the thigh. Remember
this to always know which way to hold.
- Remove the blue cap.
- Swinging motion to the thigh like so.
- Push it until you hear the click.
- It can go through all the clothing, but make sure there is no button or
anything in the pocket while injecting.
- Keep it in place and count 10 elephants. (Why do you count? So that you
can make sure all the medication is injected in that 10 seconds).

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What to do next:
- Call 999, and you need to say ‘ANAPHYLAXIS’ or Severe Allergic
reaction if you forget to remember that— why? To elicit a fast response by
the ambulance and paramedics team.
- Please again don’t panic, lay your child on the oor and stay beside him.
- Involve her in the conversation ‘do you know why you should stay near
him? To watch for any signs if he gets better or not. A fter 5 minutes if
your son doesn’t get better or the ambulance didn’t arrive yet, you will
need to give him another shot typically just as I showed you. It’s necessary
to put your child under observation for a few hours, as there is the risk of
delayed reaction. Your child’s health and safety is our priority’.
Safety netting:‘we can refer your child to an Allergy Clinic where he can be
assessed further. Make sure that you replace the two EpiPens because it is a
SINGLE USE, from the nearest Pharmacy or GP. We can set a reminder for
that. Make sure his school and anyone taking care of him knows about his
condition and let him carry an Epi-pen all the time, in the hard covering box.’
- Remind her the signs to look for in a severe allergic reaction: SOB,
Cyanosis, Rash, Wheeze, swelling of lips or Lump in the throat, fainting.
- Offer a Lea et with all the information she might need later.

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Urine Dipstick Test

Scenario
Where you are:
You are an FY2 in the Medicine Department.
Who the Student is:
Jaden Smith, a nurse who started her rst day in clinical
attachment wants to learn about the urine dipstick test.
Special Note:
Jaden has a urine sample with her and has taken consent from the patient to use it
for teaching.
What you must do:
Please talk to Jaden and teach her about the urine dipstick test. Don’t ask Jaden
to repeat anything.

Student's questions:
- What are the causes of raised protein in urine?
- What are the causes of blood in urine?
Available equipment:
- Urine pot
- Apron
- Stop watch

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Approach
- Smile
- Introduce yourself and explain your role ‘Hey, you must be Jaden if I am
not wrong. I am X working in this department’.
- ID check: Done with the introduction part above.
- Build rapport: Ask about work/ How is her rst day going… etc.
- Main concern: Copy the concern from the notes ‘I understand you are here
today to learn about the Urine Dipstick Test am I right?’ Yes, de nitely I
would love to show you how to do it. I appreciate that you are already lled
with so much enthusiasm’.
- Assess knowledge (4 W):
- So, before we start could you tell me What do you know about it in
particular?
- What exactly do you want to know about it?
- Why do you want to know about it? Any reasons in particular?
- Do you know why we do it? And do you know when we do it? We
perform a urine dipstick to detect multiple conditions such as urine
infections and diabetes complications. The test is usually performed
in any patient presenting acutely unwell and in patients presenting
with symptoms suggestive of a urinary tract infection.
Teach:
Collecting materials:
- Gloves and apron: Be sterile and to prevent cross-contamination.
- Dipstick Test Kit.
- Paper Towels.
- Waste Bin.

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Urine:
- We check colour, clarity and odour.
- Colour: What if we found there is a change in colour? For example; If it
is red what might come to your mind? Red colour suggests stones or rarely
cancer, etc.
- Clarity: So, what is normal? what if it is unclear/ cloudy? we might
consider infection.
- Odor: Offensive odor suggests infection. Sweet odor: suggests glycosuria.
Urine Dipstick Container:
- Check the Expiry date and strips having the chemicals on them.
How to do it:
- Wash your hands and wear your gloves and apron.
- Remove a dipstick from the container without touching the reagent squares.
- Replace the container lid immediately to prevent oxidation.
- Insert dipstick into the sample, ensuring all reagent squares are immersed.
- Remove the dipstick and tap off any residual urine using the edge of the
container, making sure to hold the dipstick horizontally to avoid cross-
contamination of the reagent squares.
- Lay the dipstick at on a Paper towel.
- Wait for 30-120 seconds according to whatever you are looking for.
- See the urinalysis guide on the side of the testing strip container to interpret
the results.
After analyzing:
- Discard everything in its suitable place, and take off your gloves and apron.
- Sit and document everything and the ndings in the notes.
- Suggest further investigations based on urinalysis results.

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Interpretation of dipstick results:

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Subcutaneous Injection
Scenario
Where you are:
You are an FY2 in the Medicine Department.
Who the Student is:

Jamie Watson is a 2nd year medical student has been on the ward for weeks and
he would like to learn how to perform subcutaneous injections.
What you must do:
Teach the student the basics of subcutaneous injection. Don’t ask him to perform
the procedure.

Available equipment:
- Pre-filled syringe,
- Tray,
- Sanitiser,
- Mannequin,
- Cotton,
- Alcohol swap,
- Sharps bin,
- Waste bin
- Drug chart.
Student’s concerns:
- Where do you administer subcutaneous injections?
- Can you use the same site more than once?
- What medications can we use for subcutaneous injections?

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Approach
- Smile
- Introduce yourself and explain your role ‘Hey, you must be Jamie if I am
not wrong. I am X working in this department’.
- ID check: Done with the introduction part above.
- Build rapport: Ask about work/ How is his rst day going… etc.
- Main concern: Copy the concern from the notes ‘I understand you are here
today to learn about the subcutaneous injections am I right?’ Yes,
de nitely I would love to show you how to do them. I appreciate that you
are already lled with so much enthusiasm’.
- Assess knowledge (4 W):
- So, before we start could you tell me What you know about in
particular?
- What exactly do you want to know about it?
- Why do you want to know about it? Any reasons in particular?
- Do you know why we do it? And do you know when we do it?
Common routes of delivery for medications such as: insulin, low
molecular weight heparin (LMWH), and palliative medications.
Teach:
Collect Materials:
- Gloves & an apron to be sterile and to prevent cross-contamination.
- Equipment tray.
- Standard Syringe.
- Smallest syringe that will accommodate the medication volume.
- 2 needles; Injecting needle and drawing-up needle.
- The medication bottle to be administered.

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- 1 alcohol pad
- Sometimes it can come with a pre lled syringe. (No need to collect needles
and medication bottles if pre lled).
- Gauze or cotton swab.
- Sharps container/ Bin.
- The patient’s prescription.
- Injection Site chart.
Checks before the procedure:
- Introduce yourself to the patient including your name and role.
- Brie y explain what the procedure.

- Gain consent (Right to refuse ).

- Right person: ask the patient to con rm their details and then compare this
to the patient’s wristband (if present) and the prescription.
- Right drug: check the labeled drug against the prescription and ensure the
medication hasn’t expired.
- Right dose: check the drug dose against the prescription to ensure it is
correct.
- Right time: con rm the appropriate time to be administering the medication.
- Right route: check the planned route of administering drugs.
- Right to refuse: ensure that valid consent has been gained before medication
administration.
- Right documentation of the prescription and allergies.
How to do it:
- Wash your hands and wear your gloves.
- Wipe the top of the medicine bottle with an alcohol pad (one swipe clean).
- Choose the injection site.

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- Open the syringe package and put it on a clean surface.

- Insert the drawing needle into the top of the bottle at an angle of 90 degrees.
- Pull back the plunger to ll the medication.
- Remove the needle and replace it with the injecting needle. Hold the needle
upward, tap it gently, and then push the plunger.
- Use your non-dominant hand (pinching the skin increases the depth of the
subcutaneous tissue available).
- Warn the patient of a sharp scratch.
- Inject the contents of the syringe whilst holding the barrel firmly.
- Aspiration is not recommended for subcutaneous injections, as there are no
major blood vessels in the subcutaneous tissue and the risk of inadvertent
intravenous administration is minimal, however, always follow your local
guidelines.
- Remove the needle and immediately dispose of it in the sharps container.

- Apply gentle pressure over the injection site with a cotton swab or gauze for
a few minutes and mention to avoid rubbing the site.
- Replace the gauze with a plaster.
- Dispose of your equipment into an appropriate clinical waste bin.
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What to do next:
- Explain to the patient that the procedure is now complete. Thank the patient
for their time.
- Discuss post-injection care and safety netting.
- Warn the patient that it is normal for the injection site to be sore for one or
two days
- Advise that if they experience worsening pain after 48 hours, they should
seek medical review.
- Reiterate the potential complications of subcutaneous injections including
hematoma formation, persistent nodules, local irritation, and rarely
anaphylaxis.
- Document the details of the procedure and the medication administered.
Appropriate injection site:
- Abdomen: avoid injecting within a 2-inch radius around the umbilicus (this
is the preferred site if administering low molecular weight heparin).
- Upper outer aspect of the arm.
- Outer aspect of the upper thigh.
- Upper buttock.
- Do NOT use a site that is scarred, in amed, irritated, or bruised.

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ECG
Scenario
Where you are:
You are an FY2 in the Cardiology Department.
Who the Student is:
Jaden Smith, a 5th-year medical student (or a Nurse) who is undergoing a
rotation in your department has come to you to learn about ECG.
What you must do:
Talk with Jaden and teach her ECG.

Student’s concerns:
-What can we assess from ECG?
-Which conditions can we diagnose from an ECG?

Approach
- Smile
- Introduce yourself and explain your role ‘Hey, you must be Jaden if I am
not wrong. I am X working in this department’.
- ID check: Done with the introduction part above.
- Build rapport: Ask about work/ How is her rst day going… etc.
- Main concern: Copy the concern from the notes ‘I understand you are here
today to learn about ECG, am I right?’ Yes, de nitely I would love to show
you how to do them. I appreciate that you are already lled with so much
enthusiasm’.

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- Assess knowledge (4 W):

- So, before we start could you tell me What you know about in
particular?
- What exactly do you want to know about it?
- Why do you want to know about it? Any reasons in particular?
- Do you know why we do it? And do you know when we do it? We use
ECG to diagnose any heart-related issues like arrhythmias, heart
Attacks, coronary heart disease, and cardiomyopathy.
Teach
Explain to the student ECG by drawing heart and waves then tell her to take
consent when she has to do an ECG.
Always teach what the student wishes to know. If the student only wishes to
know the basics, do not teach her advanced concepts such as heart block, SVT,
VTs, etc.
Waves:
- Firstly, we need to know how ECG is recorded. Sensors are attached to
the skin which are then used to detect the electrical signals produced by
your heart each time it beats.
- These signals are recorded by a machine as waves and are looked at by
a doctor.
- There is a spark that is initiated from this point SA Node (you will have
paper and pen to draw a simple gure of the heart).
- This spark created from the SA Node travels through gates to reach all
of the heart, creating impulse (try to choose your own words, but please
choose simple words and to the point).

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- Hold the ECG, and show what everything of the drawing can be
translated to a wave in the ECG.
- SA Node creates a n impulse that produces Atrial contraction which
creates a P wave.
- When these large chambers (Ventricles) Contract they create a QRS
wave (point at it).
- After that it must have time to rest (Ventricular relaxation) which
equals this wave, which is the T wave.

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Rate and Rhythm:

- Before we can calculate the rate, we will rst have to determine
whether the tracing is regular or not, this is what we call rhythm.
- If the distance between each R wave is the same, so it is Regular and
then you can calculate the heart rate, how?
- If Regular, then you need to count the number of large boxes
between 2 R waves and divide it by 300. So, for example, if you get 4
large boxes between 2 R waves then it will be 300/4 = 75 bpm, which is
a normal heart rate.
- Do you know the normal heart rate? between 60-100 bpm.
- What if it is higher and lower than this rate? Do you know what they
are called? Arrhythmia.
- If you see them, please involve your senior because most probably
there is something that may need to be assessed quickly.

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What if the rhythm of the heart is irregular? How can we calculate the
heart rate then?
- But before that, I want to highly stress the point that if you nd the
rhythm of the heart is not regular, it is very important also to involve
your senior.
- So to calculate irregular heart rate You will count 30 large squares and
whatever the number of R waves present in these large 30 squares and
then multiply by 10.
- For example; you found 8 R waves in 30 large boxes, then you
multiply the 8 with 10 you will get 80 that is the
HR in irregular Rhythm.

If a colleague/nurse wishes to learn about MI/ST elevation, start with assessing if

they want to learn about basics (Anatomy/ waves, rate, rhythm). If they want to
know then teach them rst quickly. And then start teaching the student about
S.T. elevation. ‘If you see ST Elevation in any leads then asses the patient for
symptoms of sudden severe crushing central chest pain radiating to the left
jaw/ neck/ shoulder/ arm as it means that the patient might be having MI and
needs urgent management’.

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Basic Life Support

Scenario
Where you are:
You are an FY2 in an Accident and Emergency Department.
Who the Student is:
Alex Wilson is a 3rd-year medical student who has not attended his Basic Life
Support Class. He came today to you to learn about it now.
Special Note:
Ask the student to perform chest compressions after you teach him.

Approach
- Smile
- Introduce yourself and explain your role ‘Hey, you must be Alex if I am not
wrong. I am X working in this department’.
- ID check: Done with the introduction part above.
- Build rapport: Ask about work/ How is his rst day going… etc.
- Main concern: Copy the concern from the notes ‘I understand you are here
today to learn about basic life support, am I right?’ Yes, de nitely I would
love to show you how to do them. I appreciate that you are already lled
with so much enthusiasm’.
- Assess knowledge (4 W):
- So, before we start could you tell me What you know about in
particular?
- What exactly do you want to know about it?
- Why do you want to know about it? Any reasons in particular?

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- Do you know why we do it? And do you know when we do it? We do

BLS when someone experiences sudden cardiac arrest, respiratory
distress, or an obstructed airway. Basic life support (BLS) is a level of
medical care that is used for patients with life-threatening illnesses or
injuries until they can be given full medical care by advanced life
support providers (paramedics, nurses, physicians).
Teach
Steps of BLS
- Safety: ensure the place is safe.
- Check response: tap the patient on the shoulder and shout ‘are you
alright?’
- Call for help: assign anyone to be next tot the patient during the time. Call
2222 if you are in hospital and 999 if you are not.
- Airway: perform head tilt chin lift to check for any foreign body. Use your
little finger to remove any foreign body. If you suspect there is spinal cord
injury then check the airway by jaw thrust method.
- Breathing: listen to the breathing sounds, look for chest rise and feel for
the breath touching your face. This shouldn't take more than 10 seconds.
- Circulation: feel for the carotid pulse at the same time as checking for
breathing.
- If the patient is not breathing and has no pulse then start CPR immediately.
Chest compressions:

- Put the person on their back on a firm surface.

- Place the lower palm of your hand over the centre of the person's chest, between
the nipples.

- Place your other hand on top of the first hand. Keep your elbows straight. Place
your shoulders directly above your hands

- Push straight down on the chest at least 5 - 6 centimetres. Use your entire body
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weight, not just your arms, when doing compressions.

- Push hard at a rate of 100 to 120 compressions a minute. Allow the chest to
spring back after each push.
Rescue breaths:
- Mouth-to-mouth can be considered if a pocket mask is readily
available.
- If no mask is available, and you are not prepared to perform mouth-to-mouth,
perform continuous CPR.
- Each ventilation breath should be given over 1 second
- Alternate between providing 30 compressions and 2 rescue breaths so it
is 30:2.
DO NOT PERFORM MOUTH-TO-MOUTH ON MANIKIN!!!!!!
Using an Ambu bag for rescue breaths:
- Make sure the patient’s airway is clear of mucus and not blocked by any foreign
bodies or their own tongue.
- Tilt the patient’s head back slightly.
- Ensure the Ambu bag is sealed and connected properly. The bag should be connect
to the oxygen source.
- Place the mask tightly over the patent’s mouth and nose.
- Begin ventilation by squeezing the Ambu bag hard enough to make the patient’s
chest rise as it would with a normal breath. Squeeze once every 5-6 seconds.

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When to stop CPR?

- If help arrives. Switch to advanced life support once the resuscitation
team arrives.
- If you get tired.
- If the patient shows any signs of life.
Ask the student to perform chest compressions and correct their approach.
Could CPR cause a rib fracture?
- Yes, it may happen but the most important thing at that moment will be
saving the person's life, right?

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Paediatric BLS
Scenario
Where you are:
You are an FY2 in the paediatric department.
Who the Student is:
Alex Wilson is a 3rd-year medical student.
Your task:
Your registrar has asked you to teach Alex paediatric life support. Explain what
would you do if a 5 year old child suddenly collapsed and presented to hospital
unconscious.

Approach
- Smile
- Introduce yourself and explain your role ‘Hey, you must be Alex if I am not
wrong. I am X working in this department’.
- ID check: Done with the introduction part above.
- Build rapport: Ask about work/ How is his rst day going… etc.
- Main concern: Copy the concern from the notes ‘I understand you are here
today to learn about paediatric basic life support, am I right?’ Yes,
de nitely I would love to show you how to do them. I appreciate that you
are already lled with so much enthusiasm’.
- Assess knowledge (4 W):
- So, before we start could you tell me What you know about in
particular?
- What exactly do you want to know about it?
- Why do you want to know about it? Any reasons in particular?
- Do you know why we do it? And do you know when we do it? We do
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BLS when someone experiences sudden cardiac arrest, respiratory

distress, or an obstructed airway. Basic life support (BLS) is a level of
medical care that is used for patients with life-threatening illnesses or
injuries until they can be given full medical care by advanced life
support providers (paramedics, nurses, physicians).

Teach
Steps of BLS
- Safety: ensure the place is safe.
- Check response: tap the patient on the shoulder and shout ‘are you
alright?’ Or rub the infant’s tummy or feet to check for response.
- Call for help: assign anyone to be next to the patient during the time. Call
2222 if you are in hospital and 999 if you are not.
- Airway: perform head tilt chin lift to check for any foreign body. Use your
little finger to remove any foreign body. If you suspect there is spinal cord
injury then check the airway by jaw thrust method.
- Breathing: listen to the breathing sounds, look for chest rise and feel for
the breath touching your face. This shouldn't take more than 10 seconds.
Simultaneously look for signs of life (these include any movement,
coughing, or normal breathing).
- Circulation: Studies have shown how unreliable feeling for a pulse is in
determining presence or absence of a circulation even for trained
paediatric healthcare workers, hence the importance of the need to
look for signs of life.
- If the child’s breathing’s abnormal or absent then give 5 rescue breaths.
Rescue breaths for an infant:
- Ensure a neutral position of the head (as an infant’s head is usually flexed when
supine, this may require some gentle extension) and apply chin lift.

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- Take a breath and cover the mouth and nose of the infant with your mouth,
making sure you have a good seal.
- If the nose and mouth cannot both be covered in the older infant, the rescuer
may attempt to seal only the infant’s nose or mouth with their mouth (if the nose
is used, close the lips to prevent air escape).
- Blow steadily into the infant’s mouth and nose over 1 second sufficient to make
the chest rise visibly.
- Maintain head position and chin lift, take your mouth away, and watch for their
chest to fall as air comes out.
- Take another breath and repeat this sequence four more times.
Rescue breaths for a child over 1 year:
- Ensure head tilt and chin lift; extending the head into 'sniffing’ position.
- Pinch the soft part of the nose closed with the index finger and thumb of
your hand on their forehead.
- Open the mouth a little but maintain the chin lift.
- Take a breath and place your lips around the mouth, making sure that you
have a good seal.
- Blow steadily into their mouth over 1 second sufficient to make the chest
rise visibly.
- Maintaining head tilt and chin lift, take your mouth away and watch for the
chest to fall as air comes out.
- Take another breath and repeat this sequence four more times.
- Identify effectiveness by seeing that the child’s chest has risen and fallen in
a similar fashion to the movement produced by a normal breath.
DO NOT PERFORM MOUTH-TO-MOUTH ON
MANIKIN!!!!!!

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Using an Ambu bag for rescue breaths:

- Make sure the patient’s airway is clear of mucus and not blocked by any foreign
bodies or their own tongue.
- Tilt the patient’s head back slightly.
- Ensure the Ambu bag is sealed and connected properly. The bag should be connect
to the oxygen source.
- Place the mask tightly over the patent’s mouth and nose.
- Begin ventilation by squeezing the Ambu bag hard enough to make the patient’s
chest rise as it would with a normal breath. Squeeze once every 2-3 seconds.

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Chest compressions:
- Compress the lower half of the sternum 100-120/ min for both infants and
children.
- Depress the lower half of the sternum by at least one third of the anterior–
posterior dimension of the chest (which is approximately 4 cm for an infant and
5 cm for a child).
- Release all pressure on the chest between compressions to allow for complete
chest recoil and avoid leaning on the chest at the end of a compression.
- Continue compressions and breaths in a ratio of 15:2.

Chest compressions in infants: use a two-thumb encircling technique or 2 finger

technique.

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Chest compressions in children older than 1 year: use the heel of one hand over
the lower half of the sternum.

When to stop CPR?

- If help arrives. Switch to advanced life support once the resuscitation
team arrives.
- If you get tired.
- If the patient shows any signs of life.
Ask the student to perform chest compressions and correct their approach.
Could CPR cause a rib fracture?
- Yes, it may happen but the most important thing at that moment will be
saving the person's life, right?

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Speculum Examination
This Station can come as a teaching station or a procedure/ examination station
in the exam, so learn it in both ways following the structure of the either-way.
Speculum examination stations come as PAP Smear routine test, Menorrhagia,
PID, and follow-up test results

Scenario
Where you are:
You are an FY2 in the Gynecology and Obstetrics Department.
Who the Student is:
Sam Peterson is a 5th-year medical student who is attending a rotation at your
department, and he wants you to teach him about female pelvic examination.
What you must do:
Talk to Sam and teach him how to perform per speculum examination. Don’t ask
Sam to repeat the procedure.

Student’s questions:
- What are the indications and contraindications of speculum examination?
Room setting:
- Lamp
- Speculum
- Apron
- No specimen pots or cyto brush

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Approach
- Smile
- Introduce yourself and explain your role ‘Hey, you must be Sam if I am not
wrong. I am X working in this department’.
- ID check: Done with the introduction part above.
- Build rapport: Ask about work/ How is his rst day going… etc.
- Main concern: Copy the concern from the notes ‘I understand you are here
today to learn about pelvic examination, am I right?’ Yes, de nitely I
would love to show you how to do them. I appreciate that you are already
lled with so much enthusiasm’.
- Assess knowledge (4 W):
- So, before we start could you tell me What you know about it in
particular?
- What exactly do you want to know about it?
- Why do you want to know about it? Any reasons in particular?
- Do you know why we do it? And do you know when we do it? Female
pelvic examination includes bimanual vaginal examination and
speculum examination which is a device used to look inside the
vagina and observe the cervix. The examination is performed as part
of a complete gynecological workup in patients presenting with
abnormal vaginal bleeding or discharge, unexplained pelvic pain or a
pelvic mass.
Teach
History Taking (2mins):
- Take history according to the case and the presenting complaint.
- Explore presenting complaints properly.
- Ask about other associated symptoms.

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- Ask 4Ps.
- Ask about previous PAP Smear or speculum, what was the outcome? Any
complications?
- Ask about the contraindications of PAP Smear and Speculum Examination.
PAP Smear contraindications:
- Active menstruation.
- Active vaginal bleeding.
- Recent sexual intercourse.
- Recent use of spermicidal gel.
- Pregnancy.
Speculum Examination contraindications:
- Uterine prolapse.
- Painful cysts.
Do the procedure or examination (4 mins):
1. Start with thanking the patient for answering your questions
2. For the patient: Explain why are you examining the patient
3. For the patient: Explain that the examination won’t be painful but could be
uncomfortable
4. For the patient: Explain what you are going to do during the examination
5. For you: Explain how you want the patient to be positioned
6. For you: Explain how you want the patient to be exposed
7. For you: Explain the contraindications of the examination if present
8. For both of you: Inform the patient that a chaperone will be present
9. For both of you: Inform the patient that you will maintain their privacy
10.For both of you: Finally gain consent by asking ‘ Do I have your consent to
proceed?’’

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“Thank you. Mrs. X for answering my questions. Now I would like to record
your blood pressure, heart rate, respiratory rate, temperature and oxygen
saturation. I will also perform a general physical examination. Now I would
like to perform a speculum exam to examine your cervix and take a sample of
the discharge. This will involve me inserting a lubricated instrument called a
speculum into your vagina. This won’t be painful but might be
uncomfortable, i will be as gentle as possible and you can ask me to stop at
any point. For this exam, i need you to be bare below the waist with your
undergarments off. I would also like you to lie lat on the bed, bring your
heels towards your bottom and then let your knees fall to the sides. I will
have a member of the medical team with me as a chaperone and I will
ensure your privacy. Are you happy for me to proceed?”
Once you gain consent, you can move to the mannequin to begin your
examination.
Equipment:
- Gloves.
- Lubricant.
- Speculum.
- Light source for the speculum.
- Paper towels.
- A pot of cytology preservative solution: Sure Path or Thin prep.
- Cervical brush.
- Clinical waste bin.
Procedure:
- Ask the patient if they have any pain before doing the clinical examination.
- Make sure you adjust the light before proceeding with the procedure.
- Don an apron, and a pair of non-sterile gloves, say ‘Assume I am gloved’ if
gloves are not available.
- Make sure the Lubricant bottle or packet is kept open before you start the
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procedure/ examination.
- On inspection/Palpation:
- Warn the patient that you are going to touch and inspect their external
genitalia. Look for redness, swelling, bleeding, ulcers, vaginal
discharge, scarring, vaginal atrophy, masses, female genital mutilation/
Injury.
- Separate the labia gently with your left index and left thumb and inspect
the inside of the labia.
- Ask the patient to cough and inspect for prolapse.
- Bimanual examination:
- lubricate the gloved index and middle fingers of your dominant hand.
- Carefully separate the labia using the thumb and index finger of your
non-dominant hand.
- With your palm facing laterally, gently insert the gloved index and
middle finger of your dominant hand into the vagina.
- Palpate the walls of the vagina and fornices for any irregularities or
masses.
- Examine the cervix for position and consistency.
- Examine for cervical motion tenderness by placing your non dominant
hand on the abdomen in the suprapubic region and gently moving the
cervix in all four directions with your dominant hand. Observe for pain
which can be suggestive of PID.
- Palpate the uterus by placing your non-dominant hand on the abdomen
in the suprapubic region and then push with your dominant hand inside
the vagina upwards. You should be able to feel the uterus between your
hands.
- Finally, palpate the ovaries and the fallopian tubes by positioning your
internal fingers in the left lateral fornix of the vagina and your external
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hand on the left iliac fossa, then perform deep palpation and feel for any
masses. Repeat on the right.
- Withdraw you fingers and inspect the gloves for blood or abnormal
discharge.
- Speculum (go in):
- Apply some lubricant to the blades of the speculum.
- Verbalise about the light source.
- Warn the patient you are about to insert the speculum.
- Gently insert the speculum sideways blades closed and angled
downwards.
- Once inserted, rotate the speculum 90° so that the handle is facing
upwards.
- Open the speculum blades until an optimal view of the cervix is
achieved.
- Tighten the locking nut to x the position of the blades.
- Hold the speculum with your hand and make sure that you do not leave
it.
- Inspect the cervix and vaginal walls.
- Inspect the external os: Open/Closed.
- Inspect for cervical erosion /Masses /Ulcers/ Discharge / Bleeding.
- PAP Smear (if required):
- Verbalize “I am inserting the brush deep into the vaginal canal to
reach the cervix”.
- Brush carefully around the external os 5 times 360 degrees, in a
clockwise direction to obtain a sample of cells.
- Gently remove the brush and avoid touching the speculum o r the
vaginal walls with the brush.

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- SurePath: Drop the detachable brush end into the SurePath sample pot
and discard the rest into the clinical waste bin. Place the cap on the pot
and tighten it.
- ThinPrep: Dip the brush into the ThinPrep sample pot 10 times. Then
discard it into the clinical waste bin. Place the cap on the pot and
tighten it.
- Speculum (Go out ):
- Warn the patient you are about to withdraw the speculum.
- Loosen the locking nut on the speculum and partially close the blades.
- Rotate the speculum 90°, back to its original insertion orientation,
while gently removing the speculum, inspecting the walls of the vagina
as you do so. Do not completely close the speculum to avoid pinching/
damaging the vaginal walls.
- Inspect the Speculum for any blood or Discharge
- After the Procedure/Examination:
- Document the procedure in the medical notes, and thank the patient for
their time.
- Summarise your ndings:
- Explain to the patient that her smear results will be sent to her GP in
approximately 2 to 3 weeks.
- Safety Netting:
- It is normal to have some vaginal spotting after the examination for a
few hours.
- If the spotting persists or it turns into heavy bleeding, go to the GP or
go to the hospital immediately.

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Management of Pelvic In ammatory Disease:

- Pain Killer.
- Antibiotics.
- If diagnosed at an early stage, PID can be treated with a course of
antibiotics, +/- 14 days.
- Remind the patient of the importance of completing the whole course.
- Avoidance of sexual intercourse during treatment.
- Sexual health clinic will help with partner noti cation, contact tracing,
STI screening, and swab test.
Management of menorrhagia/ Fibroid:
- Levonorgestrel intrauterine system (LNG-IUS).
- Tranexamic acid.
- Anti-in ammatory medications.
- Surgery to remove your broids may be considered if your symptoms
are particularly severe and medicine has been ineffective.
- Hysterectomy is a surgical procedure to remove the womb.
- Myomectomy is surgery to remove the broids from the wall of your
womb. It may be considered as an alternative to a hysterectomy if you'd
still like to have children.

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Inguinoscrotal Examination
Scenario
Where you are?
You are an FY2 working in the Surgery Department.
Who the Student is:
Sammy Wilson, a 5th-year medical student in clinical rotation in your
department wanted to seek help regarding learning about
inguinoscrotal examination.
What you must do:
Talk to him and teach him an inguinoscrotal examination.
Special Note:
Do not ask him to repeat the steps of the examination.

Available equipment:
- Standing mannequin.
Questions asked by the student:
- What’s the difference between direct and indirect hernia?
- What are the causes of groin lumps?

Approach
- Smile
- Introduce yourself and explain your role ‘Hey, you must be Sammy if I am
not wrong. I am X working in this department’.
- ID check: Done with the introduction part above.
- Build rapport: Ask about work/ How is his rst day going… etc.
- Main concern: Copy the concern from the notes ‘I understand you are here
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today to learn about inguinoscrotal examination, am I right?’ Yes,

de nitely I would love to show you how to do it. I appreciate that you are
already lled with so much enthusiasm’.
- Assess knowledge (4 W):
- So, before we start could you tell me What you know about it in
particular?
- What exactly do you want to know about it? Any reasons in
particular?. The medical student can ask you to teach them the
anatomy only or the examination only or both.
- Do you know why we do it? And do you know when we do it?
Inguinoscrotal examination is part of the abdominal examination. We
perform an Inguinoscrotal examination when someone presents with
an Inguinal hernia.

Teach
Do you know what is hernia?
- Hernia is a swelling that occurs when an internal part of the body pushes
through a weakness in the muscle or surrounding tissue wall.
Do you know the causes of hernia?
- Increased intra-abdominal pressure in cases of chronic cough or chronic
constipation.
Explain the Anatomy:
- Always remember the most important structure is Pubic
Tubercle.
- If you draw an imaginary line between the Pubic Tubercle and
the Anterior Superior Iliac Spine (ASIS), this line is called the
inguinal ligament.
- The super cial ring → ½ inch on top of pubic tubercle.
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- The deep ring → ½ inch on top of the midpoint of the inguinal

ligament.
- The inguinal canal → mid-way between ASIS and symphysis
pubis.

Types of inguinal hernia:

- Direct → enters through wall weakness in the inguinal canal, then
passes through Hassel Bach’s triangle → exits from the super cial
ring.
- Indirect → enters from the deep ring and passes into the inguinal
canal → exits from the super cial ring.

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Steps of Examination:
- You have to ensure patient privacy and explain the examination to
the patient and take consent.
- Tell the patient about the adequate exposure, from mid-chest to
mid-thigh, because you need to examine the abdomen, testicles,
scrotum, and mid-thigh.
- You need to check the patient’s genital area to see if this swelling is
coming from the abdomen or from the scrotum.
How to examine hernia:
- Position: you should examine the patient in a standing position.
- Inspection:
- Asses the swelling’s site, size, shape, skin on top and whether
it’s unilateral or bilateral.
- If you can’t see a swelling, ask the patient to cough.
- Ask the patient to reduce the hernia and locate the deep
inguinal ring and ask the patient to cough. If the hernia comes
out from the super cial ring then this is a direct hernia, if you
feel an impulse below your nger then this is likely an
indirect hernia.
- Palpation:
- Temperature: asses the temperature by the back of your hand
and compare to the thigh or abdomen.
- Tenderness: feel the swelling while looking at the patient’s face.
Tenderness suggests strangulation and the patient will usually
have constipation and vomiting.
- Deep palpation:
- Inguinal hernia: above and medial to the pubic tubercle.
- Femoral: below and lateral to the pubic tubercle.
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- Consistency: touch the swelling and see if it is Doughy

→omentum or fat. Elastic (like tube) → Intestine.
- While you are feeling the swelling, ask the patient to cough:
- Feel impulse → Good (no strangulation)
- No impulse → may be strangulation.
- If during palpation there is no swelling, ask the patient to
cough and do Zieman’s test.
- Zieman’s test (3 ngers test):
Indication: done when there is no apparent hernia by palpation.
Steps: Block the deep ring with your index nger, Block the
super cial ring with your middle nger, and block the saphenous
opening with your ring nger. Ask the patient to cough.
Results: Impulse felt under index suggests an indirect hernia. Impulse
felt under middle nger suggest direct hernia. Impulse felt under ring
nger suggests femoral hernia.

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- Percussion:
- Resonant note is suggestive of intestine.
- Dull note is suggestive omentum.

- Auscultation:
- Peristaltic sound is suggestive of intestine.
- Absent sounds is suggestive of omentum or
strangulation.
- After the Examination:
- Make sure you cover the patient.
Management:
- Elective repair if hernia is reducible.
- Emergency urgent laparotomy if strangulated.
- Open or laparoscopic repair → if irreducible.
Tell the student to always watch out for the RED FLAGS and to
escalate to seniors and the surgical team if he nds any of them as this
is a surgical emergency.

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Cancer Pathway
Scenario
Where you are:
You are an FY2 working in a teaching centre.
Who the student is:
A nal-year medical student, Max Hilton wants to learn about
the diagnosis and management of cancer patients.
What you must do:
Teach him and address his concerns.

Student’s questions:
- What are the cancer referral pathways?
- How to diagnose and manage a cancer a patient?

Approach
- Smile
- Introduce yourself and explain your role ‘Hey, you must be Max if I am not
wrong. I am X working in this department’.
- ID check: Done with the introduction part above.
- Build rapport: Ask about work/ How is his rst day going… etc.
- Main concern: Copy the concern from the notes ‘I understand you are here
today to learn about the cancer pathway, am I right?’ Yes, de nitely I
would love to show you how to do it. I appreciate that you are already lled
with so much enthusiasm’.

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- Assess knowledge (4 W):

- So, before we start could you tell me What you know about it in
particular?
- What exactly do you want to know about it? Any reasons in
particular?
- Do you know why we do it? And do you know when we do it? We do it
when a patient is presenting with symptoms suggestive of malignancy.
Teach
The cancer pathway is the patient's journey from the initial suspicion of
cancer through clinical investigations, diagnosis, and treatment.
This could be initiated by :
- Initial referral to a hospital by the GP.
- Assessment in the emergency department.
- Identi cation through screening programs.
What are the most common cancers in the UK?
- Breast, lung, prostate, and bowel cancer.
Do you know the symptoms of cancer, Max?
- It could be speci c for different types of cancer; lung cancer → blood in
sputum, shortness of breath. Bowel cancer → blood in stool or
alternating bowel habits. Breast cancer → lump in the breast.
- It could be non-speci c symptoms such as fever, loss of appetite, lumps
and bumps, anaemia, weight loss, and night sweats. We have a good
mnemonic to remember them FLAWS.
I t is so important to know about cancer symptoms, and how to identify them,
as the earlier we detect them the better the prognosis and treatment outcomes
for the patients.
Whenever someone comes with the above-mentioned symptoms, we will a sk

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about any other speci c symptoms for this cancer type and ask about general
symptoms or red ags (FLAWS).
After taking history, we need to examine the patient. We t a k e t h e
p a t i e n t ’ s observations, do a g e n e r a l p h y s i c a l
e x a m i n a t i o n , and do speci c systemic examination.
When we suspect cancer in any setting, we will refer the patient to a cancer
specialist, t h r o u g h t h e 2 w e e k w a i t p a t h w a y.
They will have investigations done such as routine blood tests, tumor markers,
X-rays, US, CT scans/MRI, camera tests, etc.
A biopsy is then performed to con rm the diagnosis.
We should safety net the patient about the acute symptoms of cancer, worsening
of symptoms, and about not seeing the specialist within two weeks, and if any
of this happens come back to us immediately.

How to explain the diagnosis of suspected cancer to the patient?

- We will always follow best-case worst-case scenario (could be a
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harmless growth or as sinister as cancer).

- Most patients referred to this pathway may not have cancer but it is important
to exclude a cancer diagnosis.
- But if we are certain of the diagnosis, of course, we have to break the
bad news in layers.
- We must show empathy and sympathy to the patient all the time,
explain the diagnosis to them in simple language, offer all the support
needed, and make sure they understand everything about their
condition.
- When cancer is con rmed, patient should not have to wait more than 31
days from the decision to treat to the start of treatment.

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Toddler Milestones
Scenario
Where you are?
You are an FY2 working in the Paediatric Department.
Who the student is:
Jackie Min, a nal-year medical student in a clinical rotation in your
department wants to perform a toddler development assessment.
What you must do:
Teach him how to perform a toddler development assessment.

Approach
- Smile
- Introduce yourself and explain your role ‘Hey, you must be Jackie if I am
not wrong. I am X working in this department’.
- ID check: Done with the introduction part above.
- Build rapport: Ask about work/ How is his rst day going… etc.
- Main concern: Copy the concern from the notes ‘I understand you are here
today to learn about the toddler development assessment, am I right?’ Yes,
de nitely I would love to show you how to do it. I appreciate that you are
already lled with so much enthusiasm’.
- Assess knowledge (4 W):
- So, before we start could you tell me What you know about it in
particular?
- What exactly do you want to know about it?
- Why do you want to know about it?

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- Do you know why we do it? And do you know when we do it?

Developmental milestones are skills that children should do when
they reach a certain age. It can be simple skills such as taking rst
step, smiling and waving hands. It can be more complicated skills
such eating, writing or drawing. Toddler comes from the word
toddling, which means walking unsteadily. It is the age group from 1
year to 3 years. Reaching milestones at the typical ages shows a child
is developing as expected. Reaching milestones much earlier means a
child may be advanced compared with his or her peers of the same
age. Not reaching milestones or reaching them much later than
children, and that is a Red Flag that we should watch out for and
escalate immediately.
Teach:
While assessing the developmental milestone, basically we look for 4 domains:
- Gross motor: this is how well a child can coordinate using large
muscles eg. walking, and running.
- Fine motor: this is how well a child can use small muscles such as
those at ngers, hands eg. writing, and gripping things.
- Language: this is the communication domain. This is how they talk and
understand us.
- Social/cognitive: This is how the child experiences, express and
manage their emotions and how they interact with those around them.
Now, explain the milestones from each domain and explain them by
paraphrasing and giving your examples.

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Milestone’s assessment is done through history taking, examination, and the

chart. We can complete the assessment by assessing the overall development

by using a growth chart where we can measure weight, height, and head

circumference.

Red Flags of developmental milestones:

- 2 years →If a child is not running nor walking, has no words, has poor eye

contact, or does not follow commands.

- 3 years → If a child is unable to say 3-word sentences like “I see a dog”,

frequently falling, and lack of interaction with other children.

If we nd any of these Red Flags, we have to refer them to a specialist for

further assessment and management

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Informed Consent
Scenario
Where you are?
You are an FY2 working in the Surgery Department.
Who the Student is:
Harold Thaw, a 3rd-year medical student has come to you to know about taking
consent and wants to know how essential is it to take consent and when to take
it.
What you must do:
Teach him and address his concerns.

Student’s questions:
- When should we take consent?
- What will happen in case of children and old people not having mental
capacity?
- What’s the NHS policy for Jehovah’s witness?

Approach
- Smile
- Introduce yourself and explain your role ‘Hey, you must be Harold if I am
not wrong. I am X working in this department’.
- ID check: Done with the introduction part above.
- Build rapport: Ask about work/ How is his rst day going… etc.
- Main concern: Copy the concern from the notes ‘I understand you are here
today to learn about the informed consent, am I right?’ Yes, de nitely I
would love to show you how to do it’.

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- Assess knowledge (4 W):

- What do you know about it in particular?
- What exactly do you want to know about it?
- Why do you want to know about it?
- Do you know why we do it? And do you know when we do it? Consent
to treatment means a person must permit before they receive any type
of medical treatment, test, or examination. This must be done based
on an explanation by a medical staff. Consent from a patient is
needed regardless of the procedure, whether it's a physical
examination or something else. The principle of consent is an
important part of medical ethics and human rights law.
Teach:
Consent is given by the patient to any health care personnel e.g. Nurse
arranging a blood test, a surgeon planning an operation, etc.
For consent to be valid, it must be voluntary and informed, and the person
consenting must have the capacity to make the decision.
Voluntary:
- The decision to either consent or not to consent to treatment must be made
by the person.
- Decisions must not be in uenced by pressure from medical staff, friends,
or family.
Informed:
- The person must be given all of the information about what the treatment
involves, including the bene ts and risks.
- whether there are reasonable alternative treatments and what will happen if
treatment does not go ahead.

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Capacity:
- The person must be capable of giving consent, which means they understand
the information given to them and can use it to make an informed decision.
- If an adult can make a voluntary and informed decision to consent to or
refuse a particular treatment, their decision must be respected.
- This is still the case even if the refusing treatment would result in their
death, e.g. in the case of Jehovah’s Witness, the patient might refuse blood
and blood products transfusion. If they can make voluntary and informed
decisions, then we have to respect their wishes and offer alternative plans.
- If a person can’t make a decision about their treatment and if they haven’t
appointed the lasting power of attorney(LPA) nor have advanced directives,
the treatment decision should be in the person’s best interest.
How is the consent given?
- Verbal: for minor tests and examinations: e.g. a person saying they’re happy
to have an X-ray, blood sampling.
- Written: for surgical procedures: e.g. signing a consent form for surgery
When consent is not needed:
- Emergency treatment to save patient’s life, when they are incapacitated eg if
they are unconscious, and reasons can be explained once they have
recovered.
- Additional emergency procedure during an operation, a eg tear in major
blood vessels like the aorta during an abdominal operation.
- Severely ill patients living in unhygienic conditions.
- Severe mental health condition such as schizophrenia, bipolar disorder, or
dementia, cannot consent to the treatment of their mental health (under the
Mental Health Act).

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How do we obtain consent from Children and young people:

- Children under the age of 16 can consent to their treatment if they're
believed to have enough intelligence, competence, and understanding to
fully appreciate what's involved in their treatment. This is known as being
Gillick competent
- Otherwise, someone with parental responsibility can consent for them. This
could be
- The child's mother or father
- The child's legally appointed guardian.
- A person with a residence order concerning the child.
- A local authority designated to care for the child.
- a local authority or person with an emergency protection order for the
child.
Consent and life support:
- A person may be kept alive with supportive treatments, such as lung
ventilation, without having made an advance decision, which outlines the
care they'd refuse to receive. In these cases, a decision about continuing or
stopping treatment needs to be made based on what that person's best
interests are believed to be.
- To help reach a decision, healthcare professionals should discuss the issue
with the relatives and friends of the person receiving the treatment.
- They should consider:
- What the person's quality of life will be if treatment is continued?
- How long the person may live if treatment is continued.
- Whether there's any chance of the person recovering.

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- If a young person refuses treatment, which may lead to their death or a

severe permanent injury, their decision can be overruled by the Court of
Protection. This is the legal body that oversees the operation of the Mental
Capacity Act.
Important definitions
- Lasting Power of attorney:
- Is to choose someone, often a close family member, to have lasting
power of attorney (LPA) if someone wishes to anticipate their loss of
capacity to make important decisions at a later stage.
- Someone with LPA can make decisions about your health on your
behalf, although you can choose to specify in advance certain
treatments you'd like them to refuse.
- Advance directive (living will):
- An advance decision (sometimes known as an advance decision to
refuse treatment, an ADRT, or a living will) is a decision you can make
now to refuse a speci c type of treatment at some time in the future
even if this results in death.
- This decision should be put in writing and it should include:
- The full details of the person making the decision including name,
date of birth and home address.
- The name and address of the person’s GP.
- A clear statement of the decision, identifying the treatment to be
refused and the circumstances in which the decision will apply,
explicating stating: even if life is at risk.
- The date the document was written.
- Signature of the patient and the person witnessing the signature.

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What’s the NHS policy for Jehovah’s witness?

-We need to ensure that the individual’s beliefs/preferences are
acknowledged and respected and that relevant information is provided for
the management of these patients.
- The majority of JW’s carry a ‘No Blood’ card which is an ‘Advanced
Directive’ absolutely refusing blood, which also releases clinicians from any
liability arising from this refusal.
- If a patient decides to refuse blood products, this should be clearly noted in
the case notes. If an advanced decision is presented, a copy should be
placed in the patient’s notes.
- Refusal of blood transfusion should be carefully documented in the
patient’s medical notes by the consultant/most senior doctor present, with
the reason given together with date, time and signature.

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Vaccination Teaching
Scenario
Where you are:

You are an FY2 working in the paediatric department.

Who the student is:

Mike James, a final year medical student in clinical rotation in your

department wants to learn about vaccination.

What you must do:

Teach him and address his concerns.

Student’s questions:

- If someone refuse to take vaccine due to side effects, how can we convince them?

- What are the side effects of vaccines?

- If a mother still refuses to vaccinate her child, should I contact safeguarding?

- Can children still go to school if they are not vaccinated?

- What will happen if children don't get vaccines?

Approach
- Smile
- Introduce yourself and explain your role ‘Hey, you must be Mike if I am not
wrong. I am X working in this department’.
- ID check: Done with the introduction part above.
- Build rapport: Ask about work/ How is his rst day going… etc.
- Main concern: Copy the concern from the notes ‘I understand you are here
today to learn about what do if someone refuses vaccination, am I right?’
Yes, de nitely I would love to show you how to do it. I appreciate that you
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are already lled with so much enthusiasm’.

- Assess knowledge (4 W):
- So, before we start could you tell me What you know about
vaccination in particular?
- What exactly do you want to know about it?
- Why do you want to know about it?
- Do you know why we do it? And do you know when we do it?

Teach:
What is a vaccine?
- A substance that we administer to make our immune system familiar with
viruses or bacteria, so when we get infected our bodies can ght the
infection better and cause fewer complications.
- They are inactive viruses and bacteria that are suf cient to induce the
immune system but not suf cient enough to cause the disease.
Advantages of vaccines:
- Individual level: Help to protect them and their child from many serious
and potentially deadly diseases.
- Community level: herd immunity through vaccination to protect other
people in their family and community by helping to stop diseases spreading
to people who cannot have vaccines, such as babies too young to be
vaccinated and those who are too ill to be vaccinated
- Sometimes reduce or even get rid of some diseases – if enough people are
vaccinated. Eg: polio and smallpox have been eradicated in the UK

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Vaccines side effects:
- Local side effects: pain, swelling, redness.
- Systemic side effects: fever, lymph gland enlargements. Of course, we will
have to tell the parents that they are temporary side effects and if they
usually resolve in a few days and offer paracetamol in case they persist and
cause trouble.
- Rare side effect: anaphylaxis. Of course, we will have to tell the parents
that we have a team of healthcare professionals, who will be watching over
their child for a certain period after vaccination to make sure that nothing
happens and they will be ready to take action in case something rare as
anaphylaxis happens.
Parents might have a reason to decline vaccination for their child despite
explaining advantages, a n d disadvantages. We have to:
- Respect their decision.
- They have the right to decide what is best for their child.
- We should not force them.
- Welcome them back in case they have a change of mind
- We need the parents to sign the Immunisation Refusal Form.
As vaccination is not mandatory in the UK, it is not usually required to inform
the school about vaccination status. However individual school policies may
vary with the school.

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Vaccines Timetable

, 3 in 1

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Vaccination Refusal
Scenario
Where you are:
You are an FY2 working in the paediatric department.
Who the student is:
Mike James, a final year medical student in clinical rotation in your
department wants to learn about what to do when someone refuses
vaccination.
What you must do:
Teach him and address his concerns.

Student’s questions:
- Why do people refuse vaccinations?
- Can a child attend school if he is not vaccinated?
- Do the parents need to sign any documents if they refuse to vaccinate their
child?

Approach
- Smile
- Introduce yourself and explain your role ‘Hey, you must be Mike if I am not
wrong. I am X working in this department’.
- ID check: Done with the introduction part above.
- Build rapport: Ask about work/ How is his rst day going… etc.
- Main concern: Copy the concern from the notes ‘I understand you are here
today to learn about what do if someone refuses vaccination, am I right?’
Yes, de nitely I would love to show you how to do it. I appreciate that you

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are already lled with so much enthusiasm’.

- Assess knowledge (4 W):
- So, before we start could you tell me What you know about
vaccination in particular?
- What exactly do you want to know about it? The student will tell that
you want to know what do if a parent refuses to vaccinate their child
- Why do you want to know about it?
Teach:
We should give the parents a good reason to get their child vaccinated. At the
same time, we should be transparent about vaccinations side effects as well.
Advantages of vaccines:
- Individual level: Help to protect them and their child from many serious and
potentially deadly diseases.
- Community level: herd immunity through vaccination to protect other
people in their family and community by helping to stop diseases spreading
to people who cannot have vaccines, such as babies too young to be
vaccinated and those who are too ill to be vaccinated
- Sometimes reduce or even get rid of some diseases – if enough people are
vaccinated. Eg: polio and smallpox have been eradicated in the UK
Vaccines side effects:
- Local side effects: pain, swelling, redness.
- Systemic side effects: fever, lymph gland enlargements. Of course, we will
have to tell the parents that they are temporary side effects and if they
usually resolve in a few days and offer paracetamol in case they persist and
cause trouble.
- Rare side effect: anaphylaxis. Of course, we will have to tell the parents
that we have a team of healthcare professionals, who will be watching over
their child for a certain period after vaccination to make sure that nothing
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happens and they will be ready to take action in case something rare as
anaphylaxis happens.
Concerns by parents:
- MMR and Autism: “Parents do have concerns about MMR being related to
autism, do you know how we should address the concern?”. We tell the
parents that the MMR vaccine is given around the time autism is diagnosed,
so parents tend to make false connections to it but it has been proven that
there is no foundation or link to the connection. We will have to make sure
that they understand that. Vaccines have undergone rigorous safety testing
before being introduced they’re also constantly monitored for side effects
after being introduced.
You can give examples of recent evidence demonstrating importance of
vaccines such as:
- The effect vaccines had on reducing mortality following COVID infection.
- The recent outbreak of Measles in the UK due to the loss of herd immunity
due to reduced vaccination uptake by the community.
Parents might have a reason to decline vaccination for their child despite
explaining advantages, a n d disadvantages. We have to:
- Respect their decision.
- They have the right to decide what is best for their child.
- We should not force them.
- Welcome them back in case they have a change of mind
- We need the parents to sign the Immunisation Refusal Form.
As vaccination is not mandatory in the UK, it is not usually required to inform
the school about vaccination status. However individual school policies may
vary with the school.

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