Text A: Procedural sedation and analgesia for adults in the emergency department
Patients in the emergency department often need to undergo painful, distressing or unpleasant diagnostic and therapeutic procedures as part of their care. Various combinations of analgesic, sedative and anaesthetic agents are commonly used for the procedural sedation of adults in the emergency department.

Although combinations of benzodiazepines and opioids have generally been used for procedural sedation, evidence for the use of other sedatives is emerging and is supported by guidelines based on randomised trials and observational studies. Patients in pain should be provided with analgesia before proceeding to more general sedation. The intravenous route is generally the most predictable and reliable method of administration for most agents.

Local factors, including availability, familiarity, and clinical experience will affect drug choice, as will safety, effectiveness, and cost factors. There may also be cost savings associated with providing sedation in the emergency department for procedures that can be performed safely in either the emergency department or the operating theatre.

Text B: Levels of sedation as described by the American Society of Anesthesiologists
Non-dissociative sedation
• Minimal sedation and analgesia: essentially mild anxiolysis or pain control. Patients respond normally to verbal commands. Example of appropriate use: changing burns dressings
• Moderate sedation and analgesia: patients are sleepy but also aroused by voice or light touch. Example of appropriate use: direct current cardioversion
• Deep sedation and analgesia: patients require painful stimuli to evoke a purposeful response. Airway or ventilator support may be needed. Example of appropriate use: major joint reduction
• General anesthesia: patient has no purposeful response to even repeated painful stimuli. Airway and ventilator support is usually required. Cardiovascular function may also be impaired. Example of appropriate use: not appropriate for general use in the emergency department except during emergency intubation.

Dissociative sedation: Dissociative sedation is described as a trance-like cataleptic state characterised by profound analgesia and amnesia, with retention of protective airway reflexes, spontaneous respirations, and cardiopulmonary stability. Example of appropriate use: fracture reduction.

Text C: Drug administration: General principles
International consensus guidelines recommend that minimal sedation – for example, with 50% nitrous oxide­ oxygen blend – can be administered by a single physician or nurse practitioner with current life support certification anywhere in the emergency department. Guidelines recommend that for moderate and dissociative sedation using intravenous agents, a physician should be present to administer the sedative, in addition to the practitioner carrying out the procedure.
For moderate sedation, resuscitation room facilities are recommended, with continuous cardiac and oxygen saturation monitoring, non-invasive blood-pressure monitoring, and consideration of capnography (monitoring of the concentration or partial pressure of carbon dioxide in the respiratory gases).
During deep sedation, capnography is recommended, and competent personnel should be present to provide cardiopulmonary rescue in terms of advanced airway management and advanced life support.
Text D: Drugs used for procedural sedation and analgesia in adults in the emergency department

Questions 1-7. For each question, 1-7, decide which text (A, B, C or D) the information comes from. You may use any letter more than once. In which text can you find information about

1 the point at which any necessary pain relief should be given?
2 the benefits and drawbacks of specific classes of drugs?
3 financial considerations when making decisions about sedation?
4 typical procedures carried out under various sedation levels?
5 measures to be taken to ensure a patient’s stability under sedation?
6 reference to research into alternative sedative agents?
7 patients’ levels of sensory awareness when sedated?
Questions 8-14. Answer each of the questions, 8-14, with a word or short phrase from one of the texts. Each answer may include words, numbers or both.
8 What class of drug is traditionally administered together with opioids for the purpose of procedural sedation?
9 What level of sedation is appropriate for changing burns dressings?
10 What is the only emergency department procedure for which it is appropriate to use general anaesthesia?
11 What procedure may be carried out under dissociative sedation?
12 What class of drugs is unsuitable for patients who have a history of psychosis?
13 What opioid drug should be administered using specific equipment?
14 What is the maximum overall dose of Midazolam which should be given?

Questions 15-20. Complete each of the sentences, 15-20, with a word or short phrase from one of the texts. Each answer may include words, numbers or both.
15 The majority of sedative drugs are administered via the _______________
16 General anaesthesia is the one form of sedation under which patients may have reduced_______________
17 Patients under minimal sedation will react if they are given _______________
18 Care should be taken when administering Etomidate to patients who are likely to have ______________
19 It may be helpful to use capnography to keep track of patients _____________ levels during moderate sedation.
20 Fentanyl, Morphine and Midozolam each have a ______________ , which is used to cancel out the effects of the drug.

END OF PART A. THIS QUESTION PAPER WILL BE COLLECTED

Part B. In this part of the test, there are six short extracts relating to the work of health professionals. For questions 1-6, choose answer (A, B or C) which you think fits best according to the text.

1. The manual states that the wheelchair should not be used
A. inside buildings.
B. without supervision.
C. on any uneven surfaces.

Manual extract: Kuschall ultra-light wheelchair:
Intended use: The active wheelchair is propelled manually and should only be used for independent or assisted transport of a disabled patient with mobility difficulties. In the absence of an assistant, it should only be operated by patients who are physically and mentally able to do so safely (e.g., to propel themselves, steer, brake, etc.). Even where restricted to indoor use, the wheelchair is only suitable for use on level ground and accessible terrain. This active wheelchair needs to be prescribed and fit to the individual patient’s specific health condition. Any other or incorrect use could lead hazardous situations to arise.

2. These guidelines contain instructions for staff who
A. need to screen patients for MRSA.
B. are likely to put patients at risk from MRSA.
C. intend to treat patients who are infected with MRSA.
MRSA Screening guidelines: It may be necessary to screen staff if there is an outbreak of MRSA within a ward or department. Results will normally be available within three days, although occasionally additional tests need to be done in the laboratory. Staff found to have MRSA will be given advice by the Department of Occupational Health regarding treatment. Even minor skin sepsis or skin diseases such as eczema, psoriasis or dermatitis amongst staff can result in widespread dissemination of staphylococci. If a ward has an MRSA problem, staff with any of these conditions (colonised or infected) must contact Occupational Health promptly, so that they can be screened for MRSA carriage. Small cuts and/or abrasions must always be covered with a waterproof plaster. Staff with infected lesions must not have direct contact with patients and must contact Occupational Health.

3. The main point of the notice is that hospital staff
A. need to be aware of the relative risks of various bodily fluids.
B. should regard all bodily fluids as potentially infectious.
C. must review procedures for handling bodily fluids.
Infection prevention: Infection control measures are intended to protect patients, hospital workers and others in the healthcare setting. While infection prevention is most commonly associated with preventing HIV transmission, these procedures also guard against other blood borne pathogens, such as hepatitis Band C, syphilis and Chagas disease. They should be considered standard practice since an outbreak of enteric illness can easily occur in a crowded hospital.

Infection prevention depends upon a system of practices in which all blood and bodily fluids, including cerebrospinal fluid, sputum and semen, are considered to be infectious. All such fluids from all people are treated with the same degree of caution, so no judgement is required about the potential infectivity of a particular specimen. Hand washing, the use of barrier protection such as gloves and aprons, the safe handling and disposal of ‘sharps’ and medical waste and proper disinfection, cleaning and sterilisation are all part of creating a safe hospital.

4. What do nursing staff have to do?
A. train the patient how to control their condition with the use of an insulin pump
B. determine whether the patient is capable of using an insulin pump appropriately
C. evaluate the effectiveness of an insulin pump as a long-term means of treatment.
Extract from staff guidelines: Insulin pumps: Many patients with diabetes self-medicate using an insulin pump. If you’re caring for a hospitalised patient with an insulin pump, assess their ability to manage self-care while in the hospital. Patients using pump therapy must possess good diabetes self-management skills. They must also have a willingness to monitor their blood glucose frequently and record blood glucose readings, carbohydrate intake, insulin boluses, and exercise. Besides assessing the patient’s physical and mental status, review and record pump-specific information, such as the pump’s make and model. Also assess the type of insulin being delivered and the date when the infusion site was changed last. Assess the patient’s level of consciousness and cognitive status. If the patient doesn’t seem competent to operate the device, notify the healthcare provider and document your findings.

5. The extract states that abnormalities in babies born to mothers who took salbutamol are
A. relatively infrequent.
B. clearly unrelated to its use.
C. caused by a combination of drugs.
Extract from a monograph: Salbutamol Sulphate Inhalation Aerosol:
Pregnant women: Salbutamol has been in widespread use for many years in humans without apparent ill consequence. However, there are no adequate and well controlled studies in pregnant women and there is little published evidence of its safety in the early stages of human pregnancy. Administration of any drug to pregnant women should only be considered if the anticipated benefits to the expectant woman are greater than any possible risks to the foetus.

During worldwide marketing experience, rare cases of various congenital anomalies, including cleft palate and limb defects, have been reported in the offspring of patients being treated with salbutamol. Some of the mothers were taking multiple medications during their pregnancies. Because no consistent pattern of defects can be discerned, a relationship with salbutamol use cannot be established.

6. What is the purpose of this extract?
A. to present the advantages and disadvantages of particular procedures
B. to question the effectiveness of certain ways of removing non-viable tissue
C. to explain which methods are appropriate for dealing with which types of wounds
Extract from a textbook: debridement: Debridement is the removal of non-viable tissue from the wound bed to encourage wound healing. Sharp debridement is a very quick method, but should only be carried out by a competent practitioner, and may not be appropriate for all patients. Autolytic debridement is often used before other methods of debridement. Products that can be used to facilitate autolytic debridement include hydrogels, hydrocolloids, cadexomer iodine and honey. Hydrosurgery systems combine lavage with sharp debridement and provide a safe and effective technique, which can be used in the ward environment. This has been shown to precisely target damaged and necrotic tissue and is associated with a reduced procedure time. Ultrasonic assisted debridement is a relatively painless method of removing non-viable tissue and has been shown to be effective in reducing bacterial burden, with earlier transition to secondary procedures. However, these last two methods are potentially expensive and equipment may not always be available.

PART C
In this part of the test, there are two texts about different aspects of healthcare. For questions 7-22, choose the answer (A, B, C or D) which you think fits best according to the text.

Text 1: Cardiovascular benefits of exercise

Cardiovascular disease (CVD) is the leading cause of death for both men and women in the United States. According to the American Heart Association (AHA), by the year 2030, the prevalence of cardiovascular disease in the USA is expected to increase by 9.9%, and the prevalence of both heart failure and stroke is expected to increase by approximately 25%. Worldwide, it is projected that CVD will be responsible for over 25 million deaths per year by 2025. And yet, although several risk factors are non-modifiable (age, male gender, race, and family history), the majority of contributing factors are amenable to intervention. These include elevated blood pressure, high cholesterol, smoking, obesity, diet and excess stress. Aspirin taken in low doses among high risk groups is also recommended for its cardiovascular benefits.

One modifiable behaviour with major therapeutic implications for CVD is inactivity. Inactive or sedentary behaviour has been associated with numerous health conditions and a review of several studies has confirmed that prolonged total sedentary time (measured objectively via an accelerometer) has a particularly adverse relationship with cardiovascular risk factors, disease, and mortality outcomes. The cardiovascular effects of leisure time physical activity are compelling and well documented. Adequate physical leisure activities like walking, swimming, cycling, or stair climbing done regularly have been shown to reduce type 2 diabetes, some cancers, falls, fractures, and depression. Improvements in physical function and weight management have also been shown, along with increases in cognitive function, quality of life, and life expectancy.

Several occupational studies have shown adequate physical activity in the workplace also provides benefits. Seat-bound bus drivers in London experienced more coronary heart disease than mobile conductors working on the same buses, as do office-based postal workers compared to their colleagues delivering mail on foot. The AHA recommends that all Americans invest in at least 30 minutes a day of physical activity on most days of the week. In the face of such unambiguous evidence, however, most healthy adults, apparently by choice it must be assumed, remain sedentary.

The cardiovascular beneficial effects of regular exercise for patients with a high risk of coronary disease have also been well documented. Leisure time exercise reduced cardiovascular mortality during a 16-year follow-up study of men in the high risk category. In the Honolulu Heart Study, elderly men walking more than 1.5 miles per day similarly reduced their risk of coronary disease. Such people engaging in regular exercise have also demonstrated other CVD benefits including decreased rate of strokes and improvement in erectile dysfunction. There is also evidence of an up to 3-year increase in lifespan in these groups.

Among patients with experience of heart failure, regular physical activity has also been found to help improve angina-free activity, prevent heart attacks, and result in decreased death rates. It also improves physical endurance in patients with peripheral artery disease. Exercise programs carried out under supervision such as cardiac rehabilitation in patients who have undergone percutaneous coronary interventions or heart valve surgery, who are transplantation candidates or recipients, or who have peripheral arterial disease result in significant short- and long-term CVD benefits.

Since data indicate that cardiovascular disease begins early in life, physical interventions such as regular exercise should be started early for optimum effect. The US Department of Health and Human Services for Young People wisely recommends that high school students achieve a minimum target of 60 minutes of daily exercise. This may be best achieved via a mandated curriculum. Subsequent transition from high school to college is associated with a steep decline in physical activity. Provision of convenient and adequate exercise time as well as free or inexpensive college credits for documented workout periods could potentially enhance participation. Time spent on leisure time physical activity decreases further with entry into the workforce. Free health club memberships and paid supervised exercise time could help promote a continuing exercise regimen. Government sponsored subsidies to employers incorporating such exercise programs can help decrease the anticipated future cardiovascular disease burden in this population.

General physicians can play an important role in counselling patients and promoting exercise. Although barriers such as lack of time and patient non-compliance exist, medical reviews support the effectiveness of physician counselling, both in the short term and long term. The good news is that the percentage of adults engaging in exercise regimes on the advice of US physicians has increased from 22.6% to 32.4% in the last decade. The empowerment of physicians, with training sessions and adequate reimbursement for their services, will further increase this percentage and ensure long-term adherence to such programmes. Given that risk factors for CVD are consistent throughout the world, reducing its burden will not only improve the quality of life, but will increase the lifespan for millions of humans worldwide, not to mention saving billions of health-related dollars.

Text 1: Questions 7-14

7. In the first paragraph, what point does the writer make about CVD?
A. Measures to treat CVD have failed to contain its spread.
B. There is potential for reducing overall incidence of CVD.
C. Effective CVD treatment depends on patient co-operation.
D. Genetic factors are likely to play a greater role in controlling CVD.

8. In the second paragraph, what does the writer say about inactivity?
A. Its role in the development of CVD varies greatly from person to person.
B. Its level of risk lies mainly in the overall amount of time spent inactive.
C. Its true impact has only become known with advances in technology.
D. Its long-term effects are exacerbated by certain medical conditions.

9. The writer mentions London bus drivers in order to
A. demonstrate the value of a certain piece of medical advice.
B. stress the need for more research into health and safety issues.
C. show how important free-time activities may be to particular groups.
D. emphasise the importance of working environment to long-term health.

10. The phrase ‘apparently by choice’ in the third paragraph suggests the writer
A. believes that health education has failed the public.
B. remains unsure of the motivations of certain people.
C. thinks that people resent interference with their lifestyles.
D. recognises that the rights of individuals take priority in health issues.

11. In the fourth paragraph, what does the writer suggest about taking up regular exercise?
A. Its benefits are most dramatic amongst patients with pre-existing conditions.
B. It has more significant effects when combined with other behavioural changes.
C. Its value in reducing the risks of CVD is restricted to one particular age group.
D. It is always possible for a patient to benefit from making such alterations to lifestyle.

12. The writer says ‘short- and long-term CVD benefits’ derive from
A. long distance walking.
B. better cardiac procedures.
C. organised physical activity.
D. treatment of arterial diseases.

13. The writer supports official exercise guidelines for US high school students because
A. it is likely to have more than just health benefits for them.
B. they are rarely self-motivated in terms of physical activity.
C. it is improbable they will take up exercise as they get older.
D. they will gain the maximum long-term benefits from such exercise.

14. What does the writer suggest about general physicians promoting exercise?
A. Patients are more likely to adopt effective methods under their guidance.
B. They are generally seen as positive role models by patients.
C. There are insufficient incentives for further development.
D. It may not be the best use of their time.

PART C. TEXT 2: POWER OF PLACEBO

Ted Kaptchuk is a Professor of Medicine at Harvard Medical School. For the last 15 years, he and fellow researchers have been studying the placebo effect- something that, before the 1990s, was seen simply as a thorn in medicine’s side. To prove a medicine is effective, pharmaceutical companies must show not only that their drug has the desired effects, but that the effects are significantly greater than those of a placebo control group. However, both groups often show healing results. Kaptchuk’s innovative studies were among the first to study the placebo effect in clinical trials and tease apart its separate components. He identified such variables as patients’ reporting bias (a conscious or unconscious desire to please researchers), patients simply responding to doctors’ attention, the different methods of placebo delivery and symptoms subsiding without treatment – the inevitable trajectory of most chronic ailments.

Kaptchuk’s first randomised clinical drug trial involved 270 participants who were hoping to alleviate severe arm pain such as carpal tunnel syndrome or tendonitis. Half the subjects were instructed to take pain-reducing pills while the other half were told they’d be receiving acupuncture treatment. But just two weeks into the trial, about a third of participants – regardless of whether they’d had pills or acupuncture – started to complain of terrible side effects. They reported things like extreme fatigue and nightmarish levels of pain. Curiously though, these side effects were exactly what the researchers had warned patients about before they started treatment. But more astounding was that the majority of participants – in other words the remaining two-thirds – reported real relief, particularly those in the acupuncture group. This seemed amazing, as no-one had ever proved the superior effect of acupuncture over standard painkillers. But Kaptchuk’s team hadn’t proved it either. The ‘acupuncture’ needles were in fact retractable shams that never pierced the skin and the painkillers were actually pills made of corn starch. This study wasn’t aimed at comparing two treatments. It was deliberately designed to compare two fakes.

Kaptchuk’s needle/pill experiment shows that the methods of placebo administration are as important as the administration itself. It’s a valuable insight for any health professional: patients’ feelings and beliefs matter, and the ways physicians present treatments to patients can significantly affect their health. This is the one finding from placebo research that doctors can apply to their practice immediately. Others such as sham acupuncture, pills or other fake interventions are nowhere near ready for clinical application.
Using placebo in this way requires deceit, which falls foul of several major pillars of medical ethics, including patient autonomy and informed consent.

Years of considering this problem led Kaptchuk to his next clinical experiment: what if he simply told people they were taking placebos? This time his team compared two groups of 18S sufferers. One group received no treatment. The other patients were told they’d be taking fake, inert drugs (from bottles labelled ‘placebo pills’) and told also, at some length, that placebos often have healing effects. The study’s results shocked the investigators themselves: even patients who knew they were taking placebos described real improvement, reporting twice as much symptom relief as the no-treatment group. It hints at a possible future in which clinicians cajole the mind into healing itself and the body – without the drugs that can be more of a problem than those they purport to solve.

But to really change minds in mainstream medicine, researchers have to show biological evidence – a feat achieved only in the last decade through imaging technology such as positron emission tomography (PET) scans and functional magnetic resonance imaging (MRI). Kaptchuk’s team has shown with these technologies that placebo treatments affect the areas of the brain that modulate pain reception. ‘It’s those advances in “hard science”‘, said one of Kaptchuk’s researchers, ‘that have given placebo research a legitimacy it never enjoyed before’. This new visibility has encouraged not only research funds but also interest from healthcare organisations and pharmaceutical companies. As private hospitals in the US run by healthcare companies increasingly reward doctors for maintaining patients’ health (rather than for the number of procedures they perform), research like Kaptchuk’s becomes increasingly attractive and the funding follows.

Another biological study showed that patients with a certain variation of a gene linked to the release of dopamine were more likely to respond to sham acupuncture than patients with a different variation – findings that could change the way pharmaceutical companies conduct drug trials. Companies spend millions of dollars and often decades testing drugs; every drug must outperform placebos if it is to be marketed. If drug companies could preselect people who have a low predisposition for placebo response, this could seriously reduce the size, cost and duration of clinical trials, bringing cheaper drugs to the market years earlier than before.

Text 2: Questions 15-22

15. The phrase ‘a thorn in medicine’s side’ highlights the way that the placebo effect
A. varies from one trial to another.
B. affects certain patients more than others.
C. increases when researchers begin to study it.
D. complicates the process of testing new drugs.

16. In the first paragraph, it’s suggested that part of the placebo effect in trials is due to
A. the way health problems often improve naturally.
B. researchers unintentionally amplifying small effects.
C. patients’ responses sometimes being misinterpreted.
D. doctors treating patients in the control group differently.

17. The results of the trial described in the second paragraph suggest that
A. surprising findings are often overturned by further studies.
B. simulated acupuncture is just as effective as the real thing.
C. patients’ expectations may influence their response to treatment.
D. it’s easy to underestimate the negative effect of most treatments.

18. According to the writer, what should health professionals learn from Kaptchuk’s studies?
A. The use of placebos is justifiable in some settings.
B. The more information patients are given the better.
C. Patients value clarity and honesty above clinical skill.
D. Dealing with patients’ perceptions can improve outcomes.
19. What is suggested about conventional treatments in the fourth paragraph?

A. Patients would sometimes be better off without them.
B. They often relieve symptoms without curing the disease.
C. They may not work if patients do not know what they are.
D. Insufficient attention is given to developing effective ones.

20. What does the phrase ‘This new visibility’ refer to?
A. improvements in the design of placebo studies
B. the increasing acceptance of placebo research
C. innovations in the technology used in placebo studies
D. the willingness of placebo researchers to admit mistakes

21. In the fifth paragraph, it is suggested that Kaptchuk’s research may ultimately benefit from
A. the financial success of drug companies.
B. a change in the way that doctors are paid.
C. the increasing number of patients being treated.
D. improved monitoring of patients by healthcare providers.

22. According to the final paragraph, it would be advantageous for companies to be able to use genetic testing to
A. understand why some patients don’t respond to a particular drug.
B. choose participants for trials who will benefit most from them.
C. find out which placebos induce the greatest response.
D. exclude certain individuals from their drug trials.

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