THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history from the patient, considering risk factors such as contamination, depth, and functional impairment.

The competent candidate should:

• Establish rapport and adopt a calm, reassuring manner, acknowledging the patient’s concerns about infection, scarring, and work impact.
• Clarify the mechanism of injury, including:
  • Time of injury and circumstances (glass-related injury, construction site).
  • Type of object involved (glass increases risk of a retained foreign body).
  • Depth and length of wound.
• Assess for functional impairment:
  • Numbness, weakness, or difficulty moving fingers to evaluate nerve or tendon damage.
  • Ongoing bleeding despite pressure, suggesting vascular involvement.
• Identify infection risk factors:
  • Contaminated wound, delay in seeking care, diabetes, immunosuppression.
• Review tetanus vaccination status:
  • Patient has not had a booster in over 10 years, requiring prophylaxis.
• Summarise findings and address concerns regarding healing, return to work, and procedural steps.

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Task 2: Explain the options for wound management and discuss the appropriate procedure for closure.

The competent candidate should:

• Explain wound management principles:
  • The goal is to promote healing, reduce infection risk, and minimise scarring.
• Discuss closure options:
  • Sutures – best for deep, gaping wounds that require tensile strength.
  • Adhesive strips or glue – suitable for small, superficial wounds but not ideal for high-movement areas.
  • Delayed primary closure – for high-risk wounds to prevent infection.
• Justify the best approach:
  • This wound is deep and gaping, so suturing is the most appropriate option.
• Discuss local anaesthesia:
  • Lignocaine 1% with adrenaline unless contraindicated.
• Explain the procedure step-by-step, using clear, simple language:
  • Cleansing, local anaesthetic, suturing technique, dressing application.
• Address concerns about pain, infection risk, and return to work.

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Task 3: Perform or explain the correct wound closure technique, including local anaesthesia and suture application.

The competent candidate should:

• Describe the wound preparation process:
  • Irrigation with normal saline (minimum 100 mL per cm of wound length).
  • Examine for foreign bodies using good lighting and, if necessary, imaging.
  • Apply antiseptic solution (e.g., povidone-iodine or chlorhexidine, avoiding deep tissue exposure).
• Administer local anaesthetic:
  • Infiltrate lignocaine 1% around the wound using a small-gauge needle.
  • Check for adequate anaesthesia before proceeding.
• Select appropriate sutures:
  • For the forearm: non-absorbable monofilament sutures (e.g., 4-0 nylon or prolene).
• Demonstrate a simple interrupted suturing technique:
  • Approximate wound edges without excessive tension.
  • Ensure even spacing and depth for optimal healing.
• Apply a dressing and provide post-procedure instructions, including when to remove sutures (7–10 days).

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Task 4: Provide post-procedure wound care advice, including signs of infection and follow-up.

The competent candidate should:

• Explain signs of infection:
  • Redness, warmth, swelling, pus discharge, increasing pain, fever.
• Give clear aftercare instructions:
  • Keep the wound dry for 24-48 hours.
  • Change dressings as advised, using clean hands.
  • Avoid strenuous activity to prevent dehiscence.
• Advise on tetanus prophylaxis:
  • Patient requires a booster dose due to high-risk wound and >10 years since last dose.
• Plan follow-up:
  • Suture removal in 7–10 days.
  • Return earlier if signs of infection develop.
• Provide reassurance about healing and scarring, advising on silicone gel or vitamin E after stitches are removed.

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SUMMARY OF A COMPETENT ANSWER

• Thorough history-taking, identifying wound depth, contamination risk, and functional impairment.
• Clear and structured explanation of closure options, justifying suturing as the best choice.
• Demonstration of correct wound closure technique, including anaesthesia, suturing, and dressing application.
• Post-procedure care instructions, including infection signs, tetanus vaccination, and follow-up plan.
• Patient-centred communication, addressing pain, scarring, and return to work concerns.

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PITFALLS

• Failing to assess for functional impairment (e.g., nerve or tendon damage).
• Not recognising the need for tetanus prophylaxis, given the high-risk wound and delayed vaccination.
• Over-reassuring the patient without addressing infection risks or proper wound care.
• Poor technique in explaining or performing suturing, leading to poor wound approximation or excessive tension.
• Neglecting to discuss return-to-work advice, leaving the patient uncertain about restrictions and healing time.
• Using excessive medical jargon, leading to poor patient understanding and increased anxiety.

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REFERENCES

• RACGP Guidelines – Wound Management in General Practice
• GP Exams – Repair/fixate-suture/cast/prosth dev (appl/rem) skin

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MARKING

Each competency area is on the following scale from 0 to 3.

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

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, expectations of healthcare, and the full impact of their illness experience on their lives.
1.4 Communicates effectively in routine and procedural situations.

2. Clinical Information Gathering and Interpretation

2.1 Takes a structured and thorough history to assess wound characteristics.
2.2 Interprets findings to determine the appropriate wound management strategy.

3. Diagnosis, Decision-Making and Reasoning

3.1 Assesses the wound for risk of infection and structural damage.
3.2 Determines the most appropriate closure technique.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based management plan for wound care.
4.2 Provides appropriate aftercare advice, including signs of infection and wound healing monitoring.

5. Preventive and Population Health

5.1 Discusses tetanus prophylaxis and wound care education.

6. Professionalism

6.1 Respects patient autonomy and explains the procedure before obtaining consent.

7. General Practice Systems and Regulatory Requirements

7.1 Refers appropriately if wound complexity exceeds GP management scope.

8. Procedural Skills

8.1 Demonstrates correct wound closure techniques, including suturing and steri-strip application.
8.2 Performs local anaesthesia safely.

9. Managing Uncertainty

9.1 Provides a structured approach to managing wounds with unclear infection risk or healing complications.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises high-risk wounds that require urgent intervention.

Competency at Fellowship Level

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