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BBN
Points must be taken in BBN:
1- Always take HX about what happened?
2- Always assess knowledge about what they know so you start just
after and not being repetitive of things while patient relatives are
devastated about knowing what’s happening.
3- Always ask about Support system
⮚ Who is here with you now?
⮚ Who do you live with?
⮚ Do you have any supportive family?
Scenario (1):

You are an FY2 in paediatric department 10 years old boy was

brought by the ambulance RTA CT scan showed extradural
haematoma, seniors are getting ready to take him to theatre, talk to
the parents
Massive words to explore!!!!

(1) RTA: what happened??

(2) CT: BBN 2 warning shots then CT results
(3) Consent?? +HX
(AMPLE)
Allergy Medication &medical condition previous surgery last
meal eat and drink

(So, let’s start station)

Confirm ID

I am here to talk to you about …. , is it okay to have a chat, so I will

be able to explain things in a better way
⮚ what happened?

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 ⮚ was it a small or big car?
⮚ did you witness the accident?
⮚ what did you see?
⮚ any blood from nose mouth or ear?
⮚ any head injury?
⮚ Any LOC?? Vvvvvimp
⮚ Any fit?
⮚ Anyone else got hurt?
⮚ Do you have any other children?? Did they witness the accident?
(II)Support System??

Who is with you in the hospital?

(III)Time to break the bad news!!! (2 warning shots +News)

First shot:

Well, I am afraid, I don’t have good news for you (PAUSE)

Second shot:

well, we have examined him, and we have done a CT scan, but

unfortunately the results were not what we’re hoping for. (PAUSE)
Would you like me to call….?

(SUPPORT whoever, support system)

Then the news:

The Ct scan shows bleeding in the brain

Questions will be asked?

Always play it safe and your answer should be in the middle

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Q1: Dr, is he going to die?

Well, I am sorry if you feel that way we have one of the best team,
most of children do recover, however there’s a chance that he may
not make it , let’s hope for the best.
Q2: dr is it serious?

Well, I am afraid to be the bearer of these bad news, it is quite

serious, but we’ll do our best to save him.
Q3: Dr any treatment??

Well, we can do surgery and try to remove the clot, but it can be
serious and sometimes life threatening I am sorry
Q4: Dr can’t see him?

Well, you may not be able to see him for long as he is in resuscitation
room, you can see him properly after the operation.
Q5: Dr, will he have brain damage?

Well, we can’t say much up until after surgery, but let’s hope for the
best.

Consent for the surgery??

Is it okay for us to go ahead with the operation?? AMPLE (HX for

surgery)
Any allergies? Medical conditions and medications , previous surgery
if yes explore, loose tooth (intubation), last eat or drink
Do you know his blood group?

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Do you mind if at any time we will need to give him blood? We

will run some blood tests.

Plz remember my name!! my name is … at any time you need to ask

any questions, I am here to help.
Scenario 2:

You are an FY2 dr in paediatric, 10 yrs RTA, investigations showed

pelvic fracture Bp low, pulse high talk to parents.
some scenarios as before but!!!

1- Here child has pelvic fracture.

2- Child is bleeding heavily as you can see, he is unstable So you will
mention that (Blood transfusion) will be needed and (Fluids)
3- Would it be okay if we give him blood?
4- This scenario said that investigations showed pelvic fracture so
make sure you don’t say word CT as it is not mentioned in the
scenario

Scenario 3:

You are an FY2 in medical department, Mr Alex 65 yrs presented with

headache, CT showed huge bleed in brain, he is unconsciousness but
breathing on his own. Neurosurgeon decided active intervention not
beneficial consultant decided to put him on palliative care talk to the
wife, address her concerns.
(I)Hx : focus on subarachnoid hx risk factors
Same approach is it okay if same as before ……..

What happened?

How did he describe headache?

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P2 has he even had such headache ?

Medical condition (DM/ HTN/strokes, ministrokes/kidney problem)

P3 DESA

What was he doing before ? smoking ? alcohol

MAFTOSA

Medications & blood thinners/ FH of sudden death / wife support

system (VVVimppp)
Ask wife support system:

⮚ Who is with you in the hospital?

⮚ Who do you live with?
⮚ How are you coping at the moment?
Always assess the knowledge?? Do you have an idea…??

BBN:

(Warning shots +News)

FIRST warning shot: I am afraid, I have bad news for you, we

have done CT scan, results were not what we were hoping for.
SECOND shot : would you like me to call …… (support)

Well, CT scans shows bleeding brain (PAUSE)

((Here he is going to die but tell her softly, don’t be scared to say yes
he is going to die))
Q: will he die dr?

I really wish, I could say it is not true but I am afraid he is not going
to make it>
Q: Dr, why did this happen?
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Tell her whichever risk factors you have gathered from HX Q:

dr will you keep him in the ICU?

I totally see how much you are caring well we do keep patients in the
ICU if they can’t breathe on their own or if we are expecting them to
recover
But Mr….. is unconscious but breathing on his own

Management:

⮚ Well my consultant thinks that intervention will only put more risk
and distress than benefits
⮚ I am really sorry, but he thinks that the best way is palliative care
⮚ Do you know what palliative care is??
It is giving social, psychological and spiritual support to the
patient and his family and we will try to relieve his pain and ake
sure that the patient and his realtives live in diginity

Please my name is….. at any time you want to ask any questions
or you have any challenges in looking after Mr… please don’t
hesitate to contact me.

Scenario 4:
Aorta femoral bypass surgery you are an FY2 in
surgery department 64 yrs old Sara had right sided aorta-
femoral bypass surgery due to blood clot, after operation
she developed bleeding as a complication she received 6 units
of blood nut still bleeding, she is taken to the theatre talk to
the husband
⮚ Step 1 : assess knowledge of her husband about her condition
⮚ Step 2: take Hx (mainly about the causes of bleeding)
⮚Step 3: BBN
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 ⮚ Step 4: what’s management
Hello , I am dr… are you…. ? are you husband of….? I am

here to talk to you about your wife condition But is it

okay if we have a chat about her condition?? How much

do you know about her condition?

History:

focus about causes of bleeding??

P2 previous bleeding anywhere?

Medical conditions (HTN/ bleeding disorders/ heart problem)

Previous surgeries/ any complications

P3

MAFTOSA

Medications blood thinners ?? aspirin??

FH of bleeding disorders
Support

VVVVimmp questions?

1- Have you and you wife been told about complications of surgery?
2- Who is in the hospital here?
3- Who do you and your wife live with?
4- Does she have any children?
BBN:

2 warning shots + News

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1- Well, do you have an idea, what’s happening?? I am
afraid I have bad news…
2- Would you like me to call… (support)
3- Well, Mrs… is having a massive bleeding, we have transfused 6 units
and she is now in theatre to try to stop bleeding
Q: why can’t you stop bleeding??

Why, why did this happen??

Draw for the husband explain in a simple way
Q: why did you do the surgery?

Condition was so serious that she’d have lost her legs Q:

Now she will lose her left?

I totally understand how you are thinking but 95% of do recover

without complications
Q:dr I’ve two sons, do you think I should inform them?

Unfortunately, the condition is so serious and you should inform

them.
Once again, I’m sorry if I was the bearer for this bad news, my name
is dr… at anytime…..
scenario 5:

((Ductal carcinoma in situ))

58 yrs female called to breast surgery clinic to recover her results for
breast screening mammogram &FNAB results show ductal
carcinoma in situ , talk to her !!! (BBN)
((Approach for any patient who is coming for results!!! ))

Well, I am here to discuss your test results but , is it okay if we have

a chat in order to explain results in a better way?? YES

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What made you come for results??

History:

Focus on risk factors, cancer and breast symptoms!!

1- Lump in the breast?

2- Pain in the breast?
3- Discharge from the nipple?
4- Skin over breast?
5- Trauma to breast?
6- Bleeding from the breast?
FLAWS (VVVimp)
P2 any past hx of breast issues?
Past medical conditions?
Previous surgeries in breast?
P3 DESA
Smoking / alcohol
MAFTOSA
Medications or OCP or HRT
FH of breast cancer
Support
P4
(if you don’t ask you will be fail)

BBN:
(2 warning shots + News)
1- Do you have any idea what’s happening?? I am afraid I don’t have
good news for you
2- Would you like me to call ……(support system)? 3- Well, we
have done investigation and it showed DCIS have you heard
about it ?

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 It is the presence and usual cells inside the milk duct of the
breast ,it’s an early form of breast concern (but) this particular
cancer carries good prognosis and non-invasive which means
that it doesn’t spread out of milk duct.

Management:
1- Breast specialist , unfortunately tt revolve around surgery
2- Either take unusual cells with some of normal cells around it
with or without hormonal therapy (lumpectomy)
3- Or mastectomy which is removal of the whole breast with or
without reconstructive surgery.
4- Safety netting ((FLAWS))
5- Follow up will be needed in the breast clinic
Same sentence at end of every BBN

Scenario 6:
post operative TIA or stroke (after intra cranial tumour
removal)
you are an Fy2 , 89 years old diagnosed with intracranial
tumour, she had an operation, after operation she was
noted to have left sided facial weakness, she has been by
Multi descipinary team CT showed ischemic stroke her son
is concerned talk to him
same approach
I am here to discuss your mum’s condition with you but is it
okay if we have a chat about her conditions in order to be
able to explain her condition
Assess knowledge!!
How much do you know ??
History:
Risk factors and strokes
P2

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 ⮚ Has she ever suffered (FAST)
Medical conditions?? )‫) )الحله‬the pan)
⮚ (HTN- cholesterol- DM-heart)
⮚ Previous surgery?
P3

DESA!!!

MAFTOSA

Medications blood thinners

Family history of strokes

Support :

⮚ who do you live with?

⮚ How is things at home?
⮚ How are you coping?
⮚ Any challenges?
BBN: 2 warning shots + News (stroke)
⮚ Do you an idea what stroke is??
⮚ Explain stroke ??
Management:

⮚ Senior
⮚ Medications Aspirin + statin + ACE
ttt whichever risk factor
⮚ Multidisciplinary (physiotherapist- occupational therapy –
carers- support)
⮚ Safety netting FAST 999

Scenario 7:

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 You are an FY2 40 yrs old Andrea has had two tests for HIV 2
weeks apart for confirmation discuss results with the patient
(same approach of test results!!)
∙ I can see from my notes that you are coming to discuss your
results is it okay if we have a chat about your health in order to
be able to explain results.
∙ What made you go for these results
History:

P1 : ((symptoms of STI))

pain while passing urine?

Smelly urine?

Discharge from your penis?

FLAWS + diarrhea

P2

Previous history of STI

Medical conditions

Previous surgery (((vvvimp))

P3

DESA (not very imp)

Must ask

⮚ Sexual hist
⮚ Iv drug abuse
⮚ Sharing needles
⮚ Blood transfusion
⮚ Have you been tested for HIV _ STI??
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BBN: ((2 warning shots + News)) STI

Q: Will I die

Reassure, most people nowadays live many years without any

problems, it’s just one tablet a day.
Advice to tell wife?? If he refused

Go with the refusal approach (6 steps that all you know)

Why? benefits senior

Address concern?? Ultimate risk

((Partner notification program))

Safety netting:
FLAWS +P1

Scenario 7:

Same as scenario 3 talk to son over the phone about SAH!!!

((Default Position)):

Always try to bring friends or relatives in when breaking bad news.

The default is to bring them into hospital to tell them face to
face regarding news of death.

Was it expected?

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Yes/ No Make sure there is someone with them and tell them in

person, unless they live very far away, if appropriate tell them over

the phone.

Other bad news (eg cancer)

Always make appointment to bring them in, unless insist

on speaking over the phone.

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