CASE INFORMATION

Case ID: LC-004
Case Name: James Carter
Age: 28 years
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2024
ICPC-2 Codes: S18 (Laceration/Cut)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Communicates clearly with the patient about wound care and management. 1.2 Explains the risks and benefits of treatment options, including wound closure techniques. 1.3 Addresses patient concerns about infection, scarring, and return to work.
2. Clinical Information Gathering and Interpretation	2.1 Takes a thorough history, including mechanism of injury, contamination risk, and tetanus status. 2.2 Assesses wound depth, extent, and involvement of underlying structures (tendons, nerves, vessels).
3. Diagnosis, Decision-Making and Reasoning	3.1 Determines the appropriate wound management strategy (closure vs. open healing). 3.2 Identifies red flags requiring referral (deep wounds, neurovascular compromise, foreign body).
4. Clinical Management and Therapeutic Reasoning	4.1 Provides appropriate pain relief and wound care (cleaning, irrigation, dressing). 4.2 Selects the correct closure method (sutures, glue, Steri-Strips) and arranges follow-up.
5. Preventive and Population Health	5.1 Ensures tetanus prophylaxis is considered based on wound type and vaccination status.
6. Professionalism	6.1 Demonstrates professional and ethical conduct in wound management and decision-making.
7. General Practice Systems and Regulatory Requirements	7.1 Documents the wound assessment, treatment plan, and follow-up instructions appropriately.
8. Procedural Skills	8.1 Demonstrates correct wound cleansing, irrigation, and closure technique. 8.2 Provides clear aftercare instructions to prevent infection and optimise healing.
9. Managing Uncertainty	9.1 Recognises when to refer for surgical review or imaging (suspected deep tissue involvement, retained foreign body, complex wounds).

CASE FEATURES

Consideration of occupational factors (manual labourer, needs full function of arm).
A 28-year-old male presents with a deep laceration on his left forearm, sustained while cutting wood with a utility knife.
The case involves wound assessment, cleaning, pain relief, and decision-making about closure (sutures vs. conservative management).
The patient is concerned about scarring, infection, and when he can return to work.
Discussion about tetanus prophylaxis and wound infection prevention.

INSTRUCTIONS

You have 15 minutes to complete the tasks for this case.

You should treat this consultation as if it is face to face.

You are not required to perform an examination.

A patient record summary is provided for your information.

Perform the following tasks:

Take a focused history of the mechanism of injury, contamination risk, and functional impact.
Explain your assessment, including wound depth, need for closure, and tetanus status.
Provide an appropriate management plan, including pain relief, wound closure, and infection prevention.
Address patient concerns, including return to work, healing expectations, and scar management.

SCENARIO

James Carter is a 28-year-old carpenter who presents with a laceration on his left forearm. He was cutting wood with a utility knife when the blade slipped and sliced into his forearm. He immediately applied pressure with a cloth, and the bleeding has slowed, but the wound still looks deep and gaping. He is worried about scarring, infection, and how long he will need to take off work.

James reports no numbness or loss of movement, and he can wiggle his fingers and flex his wrist without difficulty. However, he describes throbbing pain around the wound. He has not had a tetanus booster in over 10 years and is unsure if stitches are necessary.

Your role is to assess the wound, determine the best treatment option, and provide a clear management plan.

PATIENT RECORD SUMMARY

Patient Details

Name: James Carter
Age: 28 years
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Nil regular

Past History

No chronic medical conditions
No previous major injuries

Social History

Works as a carpenter, involving manual work and heavy tool use
Non-smoker, occasional alcohol use

Family History

No significant family medical history

Smoking & Alcohol

Non-smoker
Drinks occasionally (1-2 standard drinks per week)

Vaccination and Preventive Activities

Last tetanus booster over 10 years ago

ROLE PLAYER INSTRUCTIONS

Just like a consultation with a doctor, the candidate will ask you a series of questions.
The OPENING LINE is always to be said exactly as written. This is the only part of the script
which will be the same for all candidates. Where the candidate goes after the opening line is
up to them.

The remainder of the information is to be given based on the questions asked by the
candidate.

The information in the following script are core pieces of information. The core pieces of
information will not necessarily follow the order in the script but should be given when cued
by the candidate’s question.

GENERAL INFORMATION can be given relatively freely. After the opening line, most
candidates will ask an open question like “Can you tell me more about that?” You can provide
the GENERAL INFORMATION in response to that sort of question.

SPECIFIC INFORMATION should only be given when the candidate asks a relevant question.
Candidates don’t need to ask for all the information in the SPECIFIC INFORMATION section,
but all the relevant information is given there should they want to.

Each line or dot point in the SPECIFIC INFORMATION section is an appropriate chunk of
information which can be provided to the candidate when asked a relevant question.

Do not give extra information than asked.

Do not provide details which are not given in the information chunks (i.e.: do not elaborate
or ad-lib).

If the candidate asks a question that is not given in the script, the best way to respond is with
a generic response indicating there is no problem. For example:

Candidate: “How many hours do you sleep?”
Response: “I’m sleeping fine.” / “I don’t have any concerns about my sleep.”

The case may have specific QUESTIONS to ask the candidate. You can start asking the
QUESTIONS if the candidate asks about your ideas or concerns or questions.

Ask the other questions in a conversational way. You do not need to ask all the questions. The
aim should be to ask most of the questions but without interrupting the candidate.

The Patient Record Summary is also included. This is not part of the script but is included for
your general information.

If you need help in understanding any of the medical information in the script, ask the College
examiner who will be with you, and they can help to explain the terms or the conditions.

ROLE-PLAYER SCRIPT

Opening Line

“Doctor, I cut my arm with a knife at work. It’s pretty deep, and I think I might need stitches. I just want to make sure it doesn’t get infected or leave a bad scar.”

General Information

Your name is James Carter, and you are a 28-year-old carpenter. You were at work earlier today, cutting wood with a utility knife, when the blade slipped and sliced into your left forearm. The cut happened about an hour ago, and at first, it bled a lot, but after applying pressure with a cloth, the bleeding slowed down significantly. You are here now because the wound looks deep and open, and you aren’t sure if it needs stitches.

You are concerned about infection, scarring, and how long this will take to heal. Your job requires full use of your hands and arms, and you can’t afford to take too much time off work. You are also worried about whether you need a tetanus shot, as you haven’t had one in over 10 years.

You haven’t taken any painkillers yet, and the pain is throbbing but tolerable. You haven’t noticed any numbness or tingling, and you can still move your fingers and wrist normally. You just want to make sure it is cleaned properly, stitched if needed, and heals well without complications.

Specific Information (Only Provide if Asked Relevant Questions)

Symptoms and Functional Impact

The pain is moderate and throbbing, especially around the edges of the wound.
The bleeding has slowed, but when you remove pressure, some oozing is still present.
The wound looks deep and gaping, but you haven’t seen any exposed muscle or bone.
You can fully move your wrist, fingers, and hand without any difficulty.
You haven’t noticed any numbness or tingling in your hand or arm.

Work Situation

You work as a carpenter, so your job involves lifting, gripping tools, and fine hand movements.
If the wound is bandaged or stitched, you want to know if you can still work or if you will need time off.
You are concerned about how long it will take to heal, as you can’t afford to be off work for too long.

Concerns and Expectations

You want to avoid infection and are not sure if antibiotics are needed.
You are worried about scarring and hope stitches will help it heal neatly.
You haven’t had a tetanus shot in over 10 years, so you want to know if you need one.
You hope the doctor can clean it up and stitch it today so you don’t need to go to the hospital.
You don’t want to be told to rest it for too long, as you need to work to support yourself.

Emotional Cues and Behaviour

At first, you are calm and cooperative, but you show concern about how serious the wound is.
If the doctor suggests stitches, you nod in agreement, saying:
- “Yeah, that’s probably a good idea. I don’t want this to heal badly.”
If the doctor hesitates about whether stitches are needed, you press for an answer, saying:
- “I’d rather be safe than sorry. What would you do if it was your arm?”
If the doctor mentions time off work, you seem frustrated and say:
- “I really can’t afford to be off for too long. Is there any way I can still do some light duties?”
If the doctor recommends a tetanus shot, you sigh but agree, saying:
- “I guess it’s better to be safe.”
If the doctor does not offer antibiotics, you might ask about them directly, saying:
- “Are you sure I don’t need antibiotics? It’s a deep cut, and I work with wood all day.”

Questions for the Candidate

You should naturally ask these questions during the consultation:

“Do you think this needs stitches, or can it heal on its own?”
“How long will it take to heal? When can I get back to work?”
“Do I need antibiotics to prevent infection?”
“Will this leave a big scar? Is there anything I can do to make it heal better?”
“Since I haven’t had a tetanus shot in years, do I need one now?”
“How do I take care of the wound after this? Do I need to change the dressing every day?”
“Will I be able to bend my arm properly while it’s healing?”

Possible Responses to the Doctor’s Suggestions

If the Doctor Recommends Stitches:

You nod in agreement, saying:
- “Yeah, I don’t want it opening up again later.”
If they mention a local anaesthetic, you look slightly nervous, asking:
- “Will the injection hurt a lot?”

If the Doctor Says No Stitches Are Needed:

You look unsure, saying:
- “Are you sure? It looks pretty deep to me.”
If they explain why glue or Steri-Strips are enough, you reluctantly agree, but you still ask:
- “Will it stay closed properly without stitches?”

If the Doctor Suggests a Tetanus Shot:

You sigh but agree, saying:
- “I suppose it’s better to be safe.”

If the Doctor Mentions Time Off Work:

You look frustrated, saying:
- “Is there any way I can do some light work instead of taking full time off?”

If the Doctor Doesn’t Suggest Antibiotics:

You ask directly, saying:
- “Are you sure I don’t need antibiotics? I work with wood all day, and it’s hard to keep everything clean.”
If they explain why antibiotics aren’t needed, you nod but remain cautious, saying:
- “Okay, but I’ll keep an eye on it.”

Final Behaviour and Conclusion

If the doctor explains things clearly and provides a solid plan, you feel reassured and say:
- “Alright, I’ll follow the instructions. Thanks, doc.”
If they fail to address your concerns, you may ask again about infection risks or healing time.
You leave the consultation with a clear plan for wound care, closure, and follow-up.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a focused history of the mechanism of injury, contamination risk, and functional impact.

The competent candidate should:

Use open-ended questions to establish the mechanism of injury (sharp utility knife cut, depth, force, and time of injury).
Determine contamination risk, including exposure to dirt, wood splinters, or chemicals at the worksite.
Assess bleeding, swelling, and signs of infection such as redness, warmth, pus, or systemic symptoms (fever).
Clarify functional impact, checking for finger and wrist mobility, grip strength, and sensation to rule out tendon, nerve, or vascular injury.
Ask about past medical history, including previous injuries, diabetes, or conditions that may affect healing.
Assess tetanus immunisation status (last booster over 10 years ago suggests need for prophylaxis).
Identify patient concerns, such as infection, scarring, return to work, and need for stitches.

Task 2: Explain your assessment, including wound depth, need for closure, and tetanus status.

The competent candidate should:

Explain that the laceration appears deep and gaping, which increases the risk of infection and improper healing if left open.
Discuss the need for wound closure, recommending sutures as the best method for optimal healing, reduced infection risk, and improved cosmetic outcome.
Explain that if the wound was superficial and not under tension, Steri-Strips or tissue adhesive might be appropriate, but this wound requires suturing.
Address tetanus prophylaxis, advising a tetanus booster is required since the patient’s last dose was over 10 years ago.
Reassure the patient that infection risk is low with proper cleaning and care, and prophylactic antibiotics are generally not required unless signs of infection or high-risk factors are present.

Task 3: Provide an appropriate management plan, including pain relief, wound closure, and infection prevention.

The competent candidate should:

Prepare the wound:
- Clean with saline irrigation to remove contaminants.
- Assess for foreign bodies (wood splinters, dirt).
- Apply local anaesthetic (e.g., lignocaine) before suturing.
Close the wound using simple interrupted sutures, ensuring proper alignment to minimise scarring.
Apply a sterile dressing and instruct the patient on wound care, keeping it dry for 24-48 hours.
Discuss pain management:
- Paracetamol +/- ibuprofen for pain relief.
- Avoid NSAIDs if there is concern about excessive bleeding.
Tetanus prophylaxis: Administer tetanus vaccine (ADT) if indicated.
Provide follow-up instructions:
- Review in 7-10 days for suture removal.
- Monitor for infection signs: redness, swelling, increasing pain, pus.
- Seek medical attention if symptoms worsen.

Task 4: Address patient concerns, including return to work, healing expectations, and scar management.

The competent candidate should:

Reassure that most sutured lacerations heal within 10-14 days, but full strength may take up to 4-6 weeks.
Advise on return to work:
- Light duties may be possible with a protective bandage.
- Avoid excessive strain on the arm until healing is confirmed.
- Provide a medical certificate if needed.
Discuss scar management:
- Keeping the wound moist and covered promotes better healing.
- Once healed, silicone gels or vitamin E cream can help minimise scarring.
- Avoid sun exposure to prevent pigmentation changes.
Educate about infection prevention:
- Daily dressing changes as advised.
- Avoid soaking the wound in water for prolonged periods.
Offer follow-up if the patient has concerns about healing or function.

SUMMARY OF A COMPETENT ANSWER

Takes a thorough history, including injury mechanism, function, bleeding, and contamination risk.
Explains the rationale for wound closure, considering sutures for optimal healing and minimal scarring.
Addresses tetanus prophylaxis, recognising the need for vaccination.
Provides clear pain management and wound care instructions, including dressing, infection monitoring, and follow-up.
Addresses return-to-work concerns, explaining realistic healing expectations and light-duty options.

PITFALLS

Failure to assess depth properly, missing tendon, nerve, or vascular damage.
Not considering tetanus prophylaxis, especially in a manual labourer with a high-risk wound.
Inadequate wound cleaning, increasing the risk of infection and delayed healing.
Improper closure choice, leading to wound dehiscence or excessive scarring.
Failing to address return-to-work concerns, leaving the patient unclear about recovery time.
Neglecting to provide safety-netting advice, risking missed infections or wound complications.

REFERENCES

MARKING

Each competency area is assessed on the following scale:

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Communicates clearly with the patient about wound care and management.
1.2 Explains the risks and benefits of treatment options, including wound closure techniques.
1.3 Addresses patient concerns about infection, scarring, and return to work.

2. Clinical Information Gathering and Interpretation

2.1 Takes a thorough history, including mechanism of injury, contamination risk, and tetanus status.
2.2 Assesses wound depth, extent, and involvement of underlying structures (tendons, nerves, vessels).

3. Diagnosis, Decision-Making and Reasoning

3.1 Determines the appropriate wound management strategy (closure vs. open healing).
3.2 Identifies red flags requiring referral (deep wounds, neurovascular compromise, foreign body).

4. Clinical Management and Therapeutic Reasoning

4.1 Provides appropriate pain relief and wound care (cleaning, irrigation, dressing).
4.2 Selects the correct closure method (sutures, glue, Steri-Strips) and arranges follow-up.

5. Preventive and Population Health

5.1 Ensures tetanus prophylaxis is considered based on wound type and vaccination status.

6. Professionalism

6.1 Demonstrates professional and ethical conduct in wound management and decision-making.

7. General Practice Systems and Regulatory Requirements

7.1 Documents the wound assessment, treatment plan, and follow-up instructions appropriately.

8. Procedural Skills

8.1 Demonstrates correct wound cleansing, irrigation, and closure technique.
8.2 Provides clear aftercare instructions to prevent infection and optimise healing.

9. Managing Uncertainty

9.1 Recognises when to refer for surgical review or imaging (suspected deep tissue involvement, retained foreign body, complex wounds).

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD