The Core Rule: Who Takes Consent?

The person who performs the procedure (or someone who is competent to perform it) must take consent.

1. Understand the procedure - its steps, risks, benefits, and alternatives
2. Be able to answer patient questions about it
3. Ideally, be the one doing it

Applying It to Your Question

Why the ED Doctor CANNOT Take Consent

• Managed the dislocation and made the referral - their job is done
• Does not know the surgical risks, specific implants, anaesthetic approach, or post-op plan
• Cannot answer a patient who asks: "What will you do if you find a fracture during surgery?"

The Hierarchy in Practice

Who performs the procedure?
        ↓
Ortho Registrar (doing the op) ← IDEAL
        ↓ (if unavailable)
Another competent ortho doctor
        ↓ (if unavailable)
Ortho Consultant
        ↓ (NEVER)
ED Doctor ← Legally and ethically invalid

Key Teaching Points

1. Competence = the ability to perform that procedure - not just being a doctor or being senior
2. The ED reg "knowing the patient" does NOT qualify them to consent for a surgical procedure they cannot perform
3. The consultant "can but is last option" because they are competent - but in a hierarchy, the registrar who will perform the surgery is the most appropriate person
4. This protects the patient - they deserve consent from someone who truly understands what will be done to them
5. In an emergency (life-threatening, no time) - two doctors can document necessity and proceed without formal consent

Answer Based on AMC / Australian Guidelines

The Australian Legal & Ethical Framework

1. AMC Good Medical Practice - Code of Conduct (2009)

Provide patients with information they need to make decisions about their care - including the nature of the procedure, material risks, benefits, and alternatives.

2. NHMRC General Guidelines for Medical Practitioners on Providing Information to Patients (2004)

"While time constraints may cause a treating doctor to have a junior doctor explain the nature of the proposed operation - if a junior doctor fails to properly discharge the treating doctor's responsibility, the fault lies with the treating doctor."

• The nature of the illness being treated
• The proposed procedure and expected outcomes
• Material risks and benefits
• Available alternatives

3. RACS (Royal Australasian College of Surgeons) Position Paper on Informed Consent (2019)

"Disclosure of information and discussion is best performed by the surgeon who will be conducting the treatment."

4. Rogers v Whitaker (1992) - Foundational Australian Case Law

Why Each Option Applies in the AMC Context

The AMC Core Rule (memorise this)

The person taking consent must be competent to perform the procedure OR have received specialist training in advising patients about that specific procedure.

Practical AMC Exam Tip

1. Ask: "Is this person capable of performing the procedure?"
2. Ask: "Can this person explain the material risks specific to this procedure?"
3. The operating team consents - the referring team does not
4. The consultant is always an option but not the default when a competent registrar is available

Answer: Option 4 - Chest Tube Drain (Intercostal Catheter)

Read the Clinical Clues First - This is the AMC Method

The Single Most Important Distinction in This Question

DULLNESS to percussion  →  FLUID (blood) = HAEMOTHORAX
HYPERRESONANCE          →  AIR = PNEUMOTHORAX / TENSION PNEUMOTHORAX

Why Each Option Is Right or Wrong (AMC Logic)

❌ Option 1 - Reassure

❌ Option 2 - Antibiotics

❌ Option 3 - Needle Thoracostomy

• Hyperresonance (not dullness)
• Tracheal deviation (away from affected side)
• Distended neck veins (JVD)
• Absent breath sounds
• Absent JVD if also hypovolaemic

✅ Option 4 - Chest Tube Drain (Intercostal Catheter/ICC)

• Haemothorax = blood in the pleural space
• Management = large-bore intercostal catheter (ICC/chest tube) inserted in the 5th intercostal space, mid-axillary line
• Drains blood, re-expands lung, monitors ongoing blood loss
• Per Australian thoracic trauma guidelines: "All patients with haemothorax should be considered for tube thoracostomy regardless of fluid volume"

The AMC Percussion Rule (Memorise This Table)

Full Clinical Picture of Haemothorax (Know This)

MVA / High-energy trauma
         ↓
Rib fractures → tear intercostal vessels / lung laceration
         ↓
Blood fills pleural space
         ↓
Lung compressed → ↓ breath sounds
Blood is dense → dullness on percussion
Blood loss → shock (tachycardia, hypotension)
         ↓
DIAGNOSIS = HAEMOTHORAX
         ↓
TREATMENT = Large-bore ICC (chest tube drain)

AMC Exam Tip for Chest Trauma Questions

1. Percussion note?
   • Dull → haemothorax → ICC
   • Resonant/hyperresonant → pneumothorax
2. Is it under tension? (tracheal deviation, JVD, haemodynamic collapse)
   • Yes → needle decompression FIRST, then ICC
   • No → ICC directly
3. Is there JVD absent + shock?
   • Absent JVD + shock → haemothorax (blood lost, no venous engorgement)
   • Present JVD + shock → tension pneumothorax OR cardiac tamponade

The Full Picture: Supraspinatus Tear + Biceps Tendon Injury

Part 1: Why Are They Together?

"Rupture of the long head of the biceps is COMMON when a coexisting rotator cuff tear is present."

• Firestein & Kelley's Textbook of Rheumatology

Rotator cuff tear (supraspinatus)
         ↓
Humeral head no longer centred on glenoid
         ↓
Increased mechanical load on long head of biceps tendon
         ↓
Bicipital tendinitis → eventual rupture

• "Something gave way" in front of the shoulder
• Popeye sign - visible bulge in mid-arm (biceps muscle belly drops distally)
• Bruising over the anterior shoulder
• Mild weakness of supination and elbow flexion (but elbow flexion largely preserved because the short head and coracobrachialis remain intact)

Part 2: The Treatment Answer

For Long Head of Biceps Rupture alone:

"Reassurance that pain and bruising will resolve is sufficient. Power improves over several months and surgery (biceps tenodesis) is not needed for function, although it may help the cosmetic appearance."

For Supraspinatus Tear (Rotator Cuff):

Rotator Cuff (Supraspinatus) Tear
              ↓
    Is it symptomatic?
    /                \
  No                 Yes
  ↓                   ↓
Physio/         Try conservative
observe         (3 months minimum)
              /              \
          Improves         Fails
             ↓                ↓
           Physio          Surgery
           ongoing

Part 3: The 3 Options Explained (AMC Logic)

✅ Option 1 - Physiotherapy (FIRST LINE)

"90% of patients with rotator cuff tears responded to conservative measures such as rest, analgesics, anti-inflammatory agents, and physiotherapy."

• Phase 1: Pain relief - pendulum exercises, passive ROM, posterior capsular stretch
• Phase 2: Strengthening remaining cuff muscles + deltoid + scapular stabilisers
• Phase 3: Gradual return to overhead work and sport

✅ Option 3 - Corticosteroid Injection (Adjunct, not first-line)

"Steroid and local anaesthetic injections are used when the patient has significant pain that prohibits rehabilitation. Injections may be repeated once every 3 months if needed; injection into the cuff tendon is to be avoided."

• Use when pain is blocking physiotherapy
• Max 3 injections (not more - weakens tendon)
• Subacromial space injection, NOT into the tendon itself
• Corticosteroid injection within 6 months of surgery = higher risk of revision

✅ Option 2 - Surgery (Selected patients only)

"Asymptomatic full-thickness rotator cuff tears should be treated nonoperatively. The primary indication for surgical intervention is significant pain."

• Tenotomy = just release the tendon (simpler, older patients)
• Tenodesis = shorten and reattach to humerus (active patients, preserves strength)

The AMC Summary Table

AMC Exam Key Facts to Memorise

1. LHB rupture is associated with rotator cuff tears - always check for both
2. Popeye sign = LHB rupture - diagnosis is clinical
3. Dullness of percussion = fluid - LHB rupture treatment is conservative in most cases
4. Supraspinatus = most commonly torn rotator cuff tendon
5. Injection goes into subacromial space, never the tendon directly
6. 3 months conservative trial before considering surgery for chronic tears
7. Corticosteroid within 6 months of surgery = higher revision rate (don't inject pre-op)

• Firestein & Kelley's Textbook of Rheumatology, Bicipital Tendinopathy and Rupture
• Bailey & Love's Short Practice of Surgery 28th Ed, Long head of biceps tendon rupture
• Miller's Review of Orthopaedics 9th Ed, Rotator Cuff Testable Concepts