Two hours, not two days — button-battery and magnet ingestion

Station status

This is one MedVellum formative structured clinical encounter. The scoring, prompts and performance descriptions are educational feedback tools. They are not an official college station, timing, mark allocation, pass score or reproduced examination format. The encounter assesses first-impression recognition, leadership of resuscitation, securing the airway, taking the localising radiograph and identifying the halo sign, leading the two-hour endoscopic removal pathway, giving the honey adjunct in the eligible child with its limits, anticipating the multiple-magnet counterpoint, recognising delayed complications, communication, reassessment, escalation and safe transfer of information. [1] [2]

Candidate instructions

You are the paediatric registrar called to the acute assessment room. Assess the child from the doorway and say aloud what you see. Secure the airway and breathing first, then take the focused history and mobilise the team. Request a single radiograph from nasopharynx to anus and interpret it for the halo, double-ring and step-off signs. Lead the two-hour endoscopic removal pathway. Give the honey adjunct in the eligible child while keeping its limits. Speak directly to the child and parent. Reassess after every action. Call senior, surgical or retrieval support early. Run safeguarding alongside urgent care. Finish with a structured handover and disposition plan. Say what you would assess or do; do not perform painful or distressing manoeuvres on the actor. [1]

Room setup and observable starting state

The encounter. Arjun is three and is supported on the assessment trolley by a parent. The parent holds a remote control and says simply, "He's drooling and won't drink, and the battery from this remote is missing." Arjun is alert but uncomfortable, drooling pooling secretions, with a soft stridor at rest. These are abnormalities in airway and work of breathing with a credible ingestion history. The candidate should describe these signs objectively, declare concern, call for help, secure the airway and breathing, keep the child nil by mouth, and mobilise the endoscopy team immediately rather than wait for a diagnosis. [1]

Simulation safety. Arjun remains on the trolley and is never forcibly positioned or made to obstruct. Cards or the assessor supply drooling, stridor, monitor readings and examination findings. The parent does not obstruct urgent care. [8]

Actor cues

Parent actor

• Begin with "He's drooling and won't drink, and the battery from this remote is missing." If asked about timing, answer: "I noticed the battery was gone about two hours ago. He was playing with the remote this morning."
• If asked about other objects, answer: "There are no magnets in the house that I know of, just this remote and some hearing-aid batteries in a drawer." [1]

Child actor

• Remain alert but uncomfortable early in the encounter; drool and refuse drinks consistently; follow the assessor's cue card for any change in stridor or airway. [8]

Assessor cues and clinical data

Release findings as the candidate reaches each step. Reward airway-first behaviour, the localising radiograph and the two-hour target, and penalise diagnostic-before-resuscitation behaviour and any plan to observe an oesophageal battery. [1]

Airway and breathing

Airway is patent but drooling is pooling; soft stridor at rest; respiratory rate 32, mild recession, oxygen saturation 97 percent in air. Expected strong behaviour: keep the child nil by mouth, give oxygen, position for airway safety, and prepare to protect the airway if stridor worsens or haematemesis develops; call anaesthetic support for the shared airway. [8]

Circulation

Heart rate 130, capillary refill 2 seconds, blood pressure normal for age; perfusion preserved. Expected strong behaviour: establish access, send a group and hold given the possibility of bleeding or surgery, and treat the time window as the priority over further circulation workup. [1]

The radiograph

A single radiograph nasopharynx to anus shows a round density in the upper oesophagus with a halo and double-ring on the AP view and a step-off on the lateral view. Expected strong behaviour: identify the halo, double-ring and step-off signs confirming a button battery, confirm the oesophageal position, count any magnets, and declare the two-hour endoscopic removal target. [1] [2]

The adjunct and the removal pathway

The child is three years old, drooling but able to swallow safely, with no airway compromise, no suspected perforation, no sepsis and no honey allergy. Endoscopy can begin in twenty minutes. Expected strong behaviour: give honey 10 millilitres every ten minutes up to six doses as a bridge, state the sucralfate alternative of 1 gram per 10 kilograms, name the under-twelve-months contraindication, and affirm that the adjunct never replaces or delays endoscopy. [6]

The burn at removal

Endoscopy confirms a moderate oesophageal burn and the battery is removed whole. Expected strong behaviour: grade the burn, admit for delayed-complication surveillance, arrange follow-up endoscopy and nutrition, and give a safety net naming chest pain, fever, haematemesis, dysphagia and abdominal pain. [1] [5]

The multiple-magnet counterpoint (stretch question)

The assessor introduces a second referral: a well six-year-old with two round densities in the stomach and proximal jejunum after a building-set magnet box was found open. Expected strong behaviour: classify the two magnets as high-risk even when well, remove if within endoscopic reach with surgical standby or observe closely with repeat imaging if beyond reach, and state that laxatives and induced emesis are contraindicated. [9]

Weight and escalation

The candidate must obtain a working weight for drug and device sizing. Expected strong behaviour: use a measured weight if available immediately; otherwise document a working weight from a recent reliable value, a credible parent estimate, or the trained length-and-habitus tool, and use the local paediatric cognitive aid, re-weighing at the first safe opportunity. [1]

Marking domains

Debrief prompts

• What was the time-critical threat at each stage, and what did you expect each action to change?
• Why does the honey adjunct never replace or delay endoscopy, and when is it contraindicated?
• How did the halo sign change the plan from observing a coin to removing a battery?
• Why is a well child with two magnets still high-risk, and why are laxatives contraindicated?
• What delayed complications will you watch for after removal, and how did your safety net and prevention advice address them?