Teaching adrenaline autoinjector and action-plan use — OSCE

Candidate instructions (8-minute station)

You are the paediatric registrar discharging a six-year-old boy from the emergency department after a peanut-triggered anaphylactic reaction. He improved after a single intramuscular adrenaline dose and a period of observation, and he is now well. He has a known peanut allergy and asthma. [3]

Your tasks are: [8]

1. Teach the parents how and when to use the adrenaline autoinjector, using the trainer device. [8]
2. Explain the written ASCIA action plan and what it asks them to do. [3]
3. Advise on peanut avoidance at home and at school, and how the school will be involved. [4]
4. Address the mother's fear of giving the injection and the father's belief that the reaction was a one-off. [8]

You are not expected to organise the formal allergy-clinic referral in the station, but you should name it as the next step and explain what it will do. [4]

Examiner prompt to the actors (parents)

Mother: "I'm terrified I'll hurt him with that needle, or that I'll use it when I shouldn't. What if I get it wrong?" [8]

Father: "Look, he's fine now. It was a one-off — he just ate something he shouldn't have. He's not going to have another reaction, so do we really need to carry a needle everywhere?" [8]

Marking domains

• Frame and reassurance (3): sets a calm, reassuring tone; explains that the boy is well now and that the autoinjector is the tool that keeps him well; acknowledges the parents' feelings without dismissing them; frames the conversation as "how to keep him safe" rather than "what went wrong". [8]
• Autoinjector teaching (3): demonstrates and has the parents practise with the trainer — form a fist around the device, remove the safety cap, push firmly against the outer mid-thigh (through clothes is fine), hold for the count specified, then call an ambulance; names when to use it (throat swelling, wheeze, dizziness, collapse after a trigger); reassures that giving it is safe and that not giving it is the real danger. [8]
• Action plan and avoidance (3): explains the written ASCIA action plan — the triggers, the green/amber/red steps, when to give the device and call an ambulance; advises on strict peanut avoidance, label-reading, and how the school will hold a copy of the plan and have staff trained; names the allergy-clinic referral to confirm the trigger. [3] [4]
• Communication and addressing the parents (1): addresses the mother's fear by rehearsing the device and reassuring her it is designed to be safe, and addresses the father's "one-off" belief by explaining the biphasic reaction and the risk of recurrence, so the family leaves understanding that the device must be carried at all times. [4]

Model answer — the explanatory script

"Thank you both for coming in. Your son is completely well now — the medicine he was given worked exactly as it should, and he's recovered fully. What I want to do in the next few minutes is make sure that if this ever happens again — and we'll work hard so it doesn't — you have everything you need to keep him safe. That's three things: this device, this written plan, and a few simple rules about peanut." [8]

"Let's start with the device, because that's your most important tool. This is an adrenaline autoinjector — it's the same medicine he was given here, in a device you can use yourself. Let me show you with this trainer. You form a fist around it, pull off the blue safety cap, and push the orange end firmly against the outside of his thigh, about halfway down — you can do it right through his trousers, you don't need to find skin. You hold it there for the count it tells you, and that's it — the medicine goes in. The thigh is the right place because the medicine gets into his system fastest there. I'd like you both to have a go on the trainer now." [8]

"When do you use it? The rule is simple. If he's eaten peanut, or something you think had peanut in it, and he gets a swollen throat or tongue, he starts to wheeze or struggle to breathe, he goes dizzy or pale, or he collapses — you give the device and you call an ambulance. Don't wait. The whole point of today is that early adrenaline reverses everything, and delayed adrenaline is the one thing that makes these reactions dangerous. The device is designed to be safe — giving it when you're unsure is far less risky than not giving it when he needs it." [8]

"Now, I know you're worried about hurting him with it, and that's a really common and understandable fear. The needle is very small and it's over in seconds — and the medicine itself can make him a bit shaky or his heart race for a moment, but that settles quickly and it isn't dangerous. What is dangerous is a reaction that doesn't get adrenaline. So I'd rather you use it and it turn out he didn't quite need it, than hold back when he does. You will not get in trouble for using it." [8]

"And to your question about whether it'll happen again — I want to be straight with you. The reaction today was real, and it can happen again if he's exposed to peanut. There's also something called a biphasic reaction, where the same reaction can come back hours later even without more peanut — that's why we kept him in for observation, and it's why he carries the device from now on. So we don't treat this as a one-off. We treat it as something we're now prepared for, so that if it ever does happen again, you have exactly what you need." [3]

"This is the written action plan — it has his photo on it, it names peanut as his trigger, and it sets out the steps in green, amber and red. Green is what he's like when he's well. Amber is mild signs — like a few hives — and what to do. Red is the dangerous signs — throat swelling, wheeze, dizziness, collapse — and it says: give the device and call an ambulance. You keep this with the device, you give a copy to his school, and the school will have staff trained to use the device. We'll also refer him to the allergy clinic to confirm exactly what his trigger is and to make sure his asthma plan is tight, because good asthma control is part of keeping him safe." [3] [4]

"So to finish: the device goes with him everywhere, you both know how to use it, the action plan goes to school, you read labels and avoid peanut, and you call an ambulance the moment you use the device. You're not on your own in this — the school, the allergy clinic and our team are all part of his plan. Does that all make sense, and is there anything you'd like to go over again?" [4]