She'll be right, mate OSCE by James Chua
You are doing a locum shift in a rural emergency department 2 hours by air from the nearest major referral hospital, when a 64 year old farmer drives in complaining of severe chest pain, which came on while he was shoveling manure 45 minutes ago. He had been experiencing pain like this for weeks but for the first time, this episode had not resolved with rest. The triage nurse hands you this ECG.
The man’s pain had reduced somewhat with sublingual nitrates, and aspirin had been administered at triage. He is alert, and his vital signs are:
Afebrile, HR 67, BP 180/90, SaO2 100% on RA.
His physical examination is unremarkable.
View attached: Attachment 1
Instructions for the candidate
Provide this man with advice regarding his treatment options, and make the necessary preparations for patient management and disposition.
Domains being examined
- Medical Expertise
- Health Advocacy
For the actor
You are a 64 year old dairy farmer, usually fit as a bull. You have not seen a doctor for 20 years. You do not take any medications other than your nicotine inhaler which you picked up 2 years ago when you gave up your lifetime habit of smoking. You had a vindaloo that your new immigrant neighbours gifted to you for lunch and feel that your symptoms may be just reflux from the spice overdose.
You are wondering if some Mylanta will fix you up but the fussing by everyone in the department is giving you an impending sense of doom.
When given the news that your myocytes are dying from oxygen starvation, you become concerned and demand the best treatment possible, just like the city folk.
When your options, risks and benefits are explained to you, you accept the doctor’s recommendation.
For the examiner
Domains Assessment Objectives
- Medical Expertise
- See below...
- needs to be verbalized in a way such that a layperson can give consent.
- Health Advocacy
Other Assessment Notes
The candidate needs to demonstrate a familiarity with the
Indications: (time from onset under 1Hr, unavailability of PCI within 60-90min – early presentation of this patient in conjunction with the remote location suggests that fibrinolysis is the best option in the absence of contraindications)
Contraindications: Known bleeding diathesis, major trauma, surgery, head injury within preceding 3 weeks, suspected aortic dissection (asks about/examines for associated neurological symptoms), previous ICH or stroke of unknown origin, ischaemic stroke in previous 3-6 months, CNS lesion – tumour, AVM, GI bleeding within last month, non-compressible punctures in last 24 hours)
Benefits: Effective 60-80% of the time, improved mortality – benefit approaching that of PCI in early presenters, prevents cardiac failure, and
Risks: Failure to reperfuse - compared with PCI – PCI has mortality advantage especially in cardiogenic shock and those aged over 70, late presenters – these factors do not apply in this case.
Failure of reperfusion greater in thrombolysis, PCI over 90% effective
Bleeding: HTN, Age, low weight, known disease states predisposing to bleeding
ICH in about 1-2%
eg. Peptic ulcer,
Stretokinase issues, hypotension, allergy, rupture all may be mentioned.
Relevant background history and current clinical condition needs to be shown due consideration.
Risks and benefits need to be discussed and communicated in a clear manner to the patient as part of the process in obtaining informed consent.
The candidate should also demonstrate the ability to initiate immediate management (aspirin, heparin etc.) and the need to organise suitable and expeditious disposition for this patient – retrieval to CCU facility.