Station Title: The MVA Chest Trauma Assessment
Duration: 10 minutes (2 minutes reading time, 8 minutes performance)
Location: Emergency Department (ED)
Learning Objectives
- Primary: Perform a structured, modified respiratory examination on a trauma patient.
- Secondary: Identify life-threatening complications (Tension Pneumothorax/Flail Chest).
- Communication: Demonstrate patient-centered care and trauma-informed communication.
Patient Profile
- Name: Mr. Julian Vane
- Age: 34 years old
- Gender: Male
- Ethnicity: Caucasian
- Occupation: Delivery Driver
- Social History: Non-smoker, lives with partner.
Presenting Complaint
Mr. Vane was involved in a moderate-speed motor vehicle accident (MVA) 45 minutes ago. He was the driver; the airbag deployed. He complains of sharp right-sided chest pain and increasing difficulty breathing.
Contextual Information
- History of Presenting Complaint (HPC): Pain is sharp, pleuritic (worse on inspiration), and localized to the right lateral chest. He feels “short of breath.”
- Past Medical History: Well-controlled asthma (no recent hospitalizations).
- Medications: Salbutamol PRN.
- Allergies: Penicillin (Rash).
Exam Instructions
Candidate Instructions
Mr. Julian Vane has just arrived in the ED following an MVA. Primary survey (Airway) is patent. You are required to:
- Conduct a focused physical examination of the respiratory system and relevant peripheral signs.
- Assess hemodynamic stability.
- Formulate a provisional diagnosis and briefly explain it to the patient.
- Outline the immediate investigation of choice to the examiner.Note: You do not need to take a full history. Focus on the examination.
Standardised Patient (SP) Instructions
- Demeanour: You are anxious, breathing rapidly, and wincing when you take deep breaths.
- Pain: If the candidate touches your right lateral ribs, say: “Ouch, that’s really sharp!”
- Responses: If asked how you feel, say: “I feel like I can’t get enough air in, and my chest hurts every time I breathe.”
- Specific Sign: If the candidate asks you to breathe deeply, demonstrate shallow breaths to avoid pain.
Examiner Checklist Items
- Introduces self and gains consent.
- Assesses hemodynamic stability (Vitals).
- Checks for peripheral signs of shock/trauma (CRT, Pallor, Pulses).
- Assesses Tracheal position and JVP.
- Inspects for “red marks,” bruising, and paradoxical chest movement.
- Performs percussion (identifies hyper-resonance).
- Auscultates (identifies absent breath sounds on the right).
- Maintains patient comfort (offers analgesia).
Key Clinical Findings
| Feature | Finding |
| Vital Signs | BP 105/70 mmHg, HR 115 bpm (Tachycardia), RR 28, SpO2 91% on RA. |
| General | Anxious, mildly pale, no central cyanosis. |
| Trachea | Deviated to the Left. |
| Neck Veins | JVP is distended (visible at 45 degrees). |
| Inspection | Bruising over right 4th–6th ribs; no paradoxical movement (no flail chest). |
| Palpation | Tenderness over right lateral ribs; reduced expansion on the right. |
| Percussion | Hyper-resonant on the right side. |
| Auscultation | Absent breath sounds on the right side. Heart sounds heard but faint. |
Communication Triggers (Murtagh’s Approach)
- Open-Ended Start: “Mr. Vane, I can see you are in distress. Can you tell me exactly where the pain is worst right now?”
- Empathy & Safety: “I’m going to examine you as gently as possible. If anything I do is too painful, please tell me immediately. I can arrange some pain relief for you.”
- Summarising: “So, the pain started right after the impact, it’s sharp when you breathe, and you’re feeling quite breathless. Is that correct?”
- Lay Language: Instead of “Tension Pneumothorax,” use: “It looks like air has trapped outside your lung, causing it to collapse and put pressure on your heart. We need to act quickly to release that pressure.”
Assessment & Marking Guide
| Score | Descriptor |
| Pass | Systematically follows a trauma-modified respiratory exam. Identifies tracheal deviation and absent breath sounds. Correctly diagnoses Tension Pneumothorax. Professional and empathetic. |
| Borderline | Follows structure but misses JVP or Tracheal shift. Identifies a pneumothorax but fails to recognize the “Tension” (emergency) aspect. |
| Fail | Skips vitals/peripheries. Fails to identify absent breath sounds. Disorganized approach. Ignores patient’s pain. |
Sample Answers / Model Performance
Provisional Diagnosis: Right-sided Tension Pneumothorax.
Candidate Explanation to Patient:
“Mr. Vane, based on my examination, I believe the impact has caused air to leak out of your lung and get trapped in your chest cavity. This is called a tension pneumothorax. It’s why you’re feeling so short of breath and why your heart rate is high. We need to perform a procedure right now to let that air out and help you breathe easier.”
Candidate Answer to Examiner (Management):
- Immediate Action: Needle decompression (2nd intercostal space, mid-clavicular line) followed by an Intercostal Catheter (Chest Tube).
- Investigation: Chest X-ray (CXR) once the patient is stabilized to confirm re-expansion and check for rib fractures.
- Supportive Care: High-flow oxygen and IV analgesia.