Breaking Bad News · Advanced · Ethics

Irritability and Drowsiness in Young Child Post-Injury

Practise this PLAB 2 breaking bad news station on Extradural Haemorrhage. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in paediatric intensive care. A five-year-old girl, Lily Owen, suffered a severe head injury in a fall three days ago. Imaging shows a large extradural haemorrhage with significant mass effect. Emergency neurosurgery was performed, but post-operatively she has developed severe cerebral oedema and is deteriorating. Her neurological status is critical. The PICU consultant has reviewed Lily and asked you to speak with her mother about her condition, the prognosis, and what comes next, as you have been closely involved in Lily's care since her admission. A five-year-old girl, Lily Owen, suffered a severe head injury in a fall three days ago. Imaging shows a large extradural haemorrhage with significant mass effect. Emergency neurosurgery was performed, but post-operatively she has developed severe cerebral oedema and is deteriorating. Her neurological status is critical. You must speak with her parents about her condition, the prognosis, and what comes next.

Background notes: PMH: Nil significant (healthy child previously)

What this station tests

  • Explaining extradural haemorrhage in lay terms: bleeding between skull and brain causing pressure
  • Honest uncertainty: 'we do not yet know the extent of brain injury'
  • Not assigning blame: accident, not negligence by parents or school
  • Allowing parents to sit with their child: critical for parental coping
  • Regular updates including 'no change' updates: silence increases parental anxiety

How to use your 8 minutes

  • 0-1 min — Setting: Introduce yourself. Ensure privacy. Ask what they already know (SPIKES: Perception).
  • 1-2 min — Warning Shot: Give a warning shot. 'I'm afraid I have some difficult news.' Pause and allow reaction.
  • 2-4 min — Deliver Information: Give information in small chunks. Use clear, simple language. Avoid euphemisms. Pause after key information.
  • 4-6 min — Respond to Emotion: Acknowledge and validate emotions. Allow silence. Empathic statements. Address immediate concerns.
  • 6-8 min — Plan and Support: Discuss next steps when patient is ready. Offer support resources. Arrange follow-up. Written information.

Consultation approach

The opening

Explaining a severe head injury in a child to parents is among the most distressing conversations in medicine. Lily (5) suffered an extradural haemorrhage from a playground fall, had emergency surgery, and is now in PICU with uncertain prognosis. Open with: 'Sarah, James, thank you for coming. I want to update you on Lily. Can we sit down together?'

Core approach

Explain what happened in simple terms. 'When Lily fell, the impact caused bleeding between her skull and brain. This is called an extradural haemorrhage. The blood put pressure on her brain, which is why she became drowsy. The surgeons operated to remove the blood and relieve the pressure.'

Current status: she is in intensive care, sedated, on a ventilator to let her brain recover. They cannot see her awake yet. The next 24 to 48 hours are critical. Be honest about uncertainty: 'We do not yet know the extent of any brain injury. We will assess her when the sedation is reduced.'

Parents will be in shock, guilt, anger. The mother may blame herself or the school. Respond with empathy: 'This was an accident. You did nothing wrong, and the school did nothing wrong.' Address their specific fears: will she wake up? Will she be normal? 'We hope so, but we need time to assess.'

Closing and safety netting

Next steps: reduce sedation gradually over 24 to 48 hours and assess neurological function. Repeat imaging. They can sit with Lily (this matters enormously to parents). Named nurse and consultant for ongoing updates. Regular updates even when there is no change. Chaplaincy, PALS, accommodation for parents. 'We will tell you everything as we know it.' Follow-up: hourly nursing updates, consultant review twice daily.

How examiners mark this station

Examiners will focus heavily on Domain 3 (Interpersonal Skills): how sensitively you deliver the news, whether you give a warning shot, allow silence, and respond to emotion. Domain 2 (Clinical Management) assesses the accuracy and clarity of information provided and the appropriateness of the plan discussed. Domain 1 (Data Gathering) assesses whether you established prior knowledge and readiness.

Domain 1 (Supporting)

Scores well: Clear explanation of what happened. Current status conveyed. Uncertainty acknowledged.

Costs marks: Confusing explanation. Not conveying severity.

Domain 2 (Primary focus)

Scores well: Sedation plan explained. Imaging plan. Named nurse and consultant. Parent access to child. Support services.

Costs marks: Not explaining the plan. Not arranging parent access.

Domain 3 (Primary focus)

Scores well: Empathic with devastated parents. Not assigning blame. Honest about uncertainty. Offering to stay with Lily. Regular updates.

Costs marks: Blaming. False reassurance. Clinical detachment. No updates.

Common examiner feedback (and how to fix it)

Did not demonstrate sensitivity when delivering difficult information

Fix: Always give a warning shot. Deliver the key information in one clear sentence, then stop. Allow silence. Respond to emotion before giving more detail.

Did not sufficiently recognise or respond to the patient's feelings, concerns, or expectations

Fix: After delivering bad news, your primary role shifts to emotional support. Use the NURSE mnemonic (Name, Understand, Respect, Support, Explore) to respond to the patient's reaction.

Common mistakes in this station

  1. Being falsely reassuring: 'she will be fine' is dishonest when outcome is uncertain
  2. Not allowing parents to see/sit with their child: this is essential for coping
  3. Not providing regular updates: parents left in silence assume the worst

Resitting PLAB 2?

If breaking bad news stations have been a weakness, practise the SPIKES framework until the structure is automatic. The most common resitter mistake is rushing past the emotional response. Allow genuine silence after delivering the news, and resist the urge to fill pauses with more information.

Example opening

Hello, my name is Dr [Name]. Thank you for coming in today. Before we start, can I ask if you have anyone with you, or would you like to have someone here? I have the results from your recent tests, and I'd like to go through them with you.

Frequently asked questions

How should I break the news in this extradural haemorrhage station?

Explaining a severe head injury in a child to parents is among the most distressing conversations in medicine. Lily (5) suffered an extradural haemorrhage from a playground fall, had emergency surgery, and is now in PICU with uncertain prognosis.

What are examiners marking in this extradural haemorrhage station?

Marks are won for: Clear explanation of what happened. Current status conveyed. Uncertainty acknowledged. Marks are lost for: Confusing explanation. Not conveying severity.

What is the most common mistake candidates make in this extradural haemorrhage station?

Being falsely reassuring: 'she will be fine' is dishonest when outcome is uncertain. Another frequent error: Not allowing parents to see/sit with their child: this is essential for coping.

How do I prepare for this station if I have not managed extradural haemorrhage in clinical practice?

This station rewards process over personal experience. The skill being assessed: Honest uncertainty: 'we do not yet know the extent of brain injury'. The written guidance on this page covers the full approach, and practising the consultation aloud builds the fluency the examiner is listening for.

Related cases