The clinical stations in the ACRRM multiple mini interview have a defining feature: help is a long way away. The scenario puts you in a rural clinic, a small hospital or a remote community, with the nearest tertiary centre hours away by road or air, and asks what you would do. Assessors are scoring whether you would treat what can be treated locally, call early, use retrieval and telehealth well, and know the limits of the setting. This guide covers the scenarios that recur and the structure that scores.
The scenarios
- A 55 year old farmer presents to your rural emergency department with chest pain and ST elevation. The nearest cath lab is three hours away.
- A child with a fever and a rash is brought to the clinic in a remote town.
- A woman at 36 weeks presents with abdominal pain and bleeding in a town with no obstetric service.
- A motor vehicle accident on the highway near your town with several casualties.
- A patient with a snake bite arrives at your clinic.
- A patient presents with low mood and says they have been thinking of ending their life, and the nearest mental health service is two hours away.
- A 70 year old with diabetes, heart failure and kidney disease comes for a review.
- A patient with chronic pain asks for an increase in their opioids.
The structure that scores
- Treat what can be treated now. For the infarct, thrombolysis when primary intervention is out of reach, with the state's cardiac advisory line on the phone. For the febrile child, the sepsis assessment and the first antibiotics. For the obstetric haemorrhage, the protocol with the blood bank and the obstetric advisory service involved. For the snake bite, pressure immobilisation, the bloods, the poisons information line, and antivenom with their advice. Say the specifics.
- Call early. The retrieval service, the receiving specialist, the advisory lines, as soon as the need is recognised. The delay is the retrieval team's travel time, so the call goes out before the patient is packaged, not after.
- Use telehealth. Emergency and critical care telehealth with a specialist on screen exists in every state. Say how you would use it during the wait.
- Prepare the patient and the team. The airway decision made before the retrieval team arrives, the patient packaged, the documentation ready, the family informed, the nurses allocated.
- Plan for deterioration. What you would do if the patient arrested, if the airway became threatened, if the retrieval team were delayed, if a second casualty arrived.
- Keep the clinic or hospital running. Who sees the waiting room while you are in resus.
The highway accident
A disaster scenario in miniature. Activate the local emergency plan, call ambulance and retrieval and the police, prepare the hospital with the staff you can muster, triage on arrival, treat the most urgent survivable injuries, and keep a record. Say what you would do about your own limits and about the staff afterwards. The assessors score calm prioritisation and knowledge that a plan exists.
The suicidal patient two hours from help
Safety first, then the risk assessment: intent, plans, means, risk factors, protective factors, collateral. Then the decision: whether the patient can be managed locally with a safety plan and close follow up, or needs transfer to a mental health unit, voluntarily or under the state's legislation, with the mental health advisory line and the retrieval service involved. Say how you would keep the patient safe during the wait and who in the community could help.
The chronic disease and opioid consultations
Not emergencies, and the assessors use them to test general practice judgement. For the patient with multiple conditions, prioritise what matters to the patient, use a care plan and the team, coordinate the specialists by telehealth, and address the practical barriers of distance. For the opioid request, explore the pain and its effects, assess for dependence, explain the evidence and the risks, offer alternatives and a plan, and know the state's prescribing monitoring and regulations. Say how you would keep the relationship when you say no.
What the assessors score
Treating rather than waiting, calling early, using the advisory services and telehealth, making the airway and transfer decisions yourself, knowing the limits of the setting, and seeing rural practice as a place of competence rather than fear. The common failures are the candidate who would transfer everything without treating, and the one who would manage everything alone.
Preparing
Learn your state's retrieval service, advisory lines and telehealth arrangements by name. Talk each scenario through aloud in six minutes with the retrieval call included, then have someone play the receiving specialist asking what you have done so far and throw the deterioration at the four minute mark. The structure transfers across all of them.