ACEM example: Elderly man with SAH OSCE added anonymously 

You have 3 minutes reading time. This OSCE will run for a maximum of 7 minutes.


Mr. Jones is a 55 year old man who was at work when he suddenly collapsed. He was brought in to the emergency department intubated and ventilated with a GCS of 3. CT scan showed a massive sub-arachnoid hemorrhage. He has been seen by the neurosurgeons who suggested that surgery would be unhelpful and that palliation was the best option.

Instructions for the candidate

You are to meet with Mrs Jones, who has just arrived in the ED. She knows that her husband has had a collapse at work but does not know any more than that.
Mr Jones was previously fit and well, working as a gardener.
CT shows massive SAH.
Mr Jones is currently intubated and ventilated.
GCS 3 on arrival, pupils fixed, dilated,
P 50, BP 200/120, SpO2 100%

The Neurosurgery Registrar has seen Mr Jones and discussed the CT with his consultant who agrees that with a Grade 4 SAH, fixed dilated pupils and signs of increasing ICP surgical intervention would be unhelpful. The neurosurgical team have suggested palliation. ICU is currently bed-blocked with no vacant beds and three patients waiting to be discharged to the ward. The ICU consultant suggested that the patient should be palliated in ED.

Your task is to explain to Mrs Jones the current situation and the likely outome.

Domains being examined

  • Medical Expertise
  • Prioritisation And Decision Making
  • Communication
  • Health Advocacy
  • Professionalism
The candidate has 3 minutes reading time. This OSCE is expected to run for a maximum of 7 minutes.

For the actor

You are a 50 year old lady. You have been happily married for thirty years and have two children, one working in Adelaide and one studying in Melbourne. You have good friends here but no other family close by.

Your husband works as a gardener with the council. He went to work today completely well and you were called by his work, to say that he had had a collapse and was taken to the hospital in a very serious condition. You don’t know any further information at this stage. You are obviously very concerned.

It turns out that your husband has had a massive cerebral haemorrhage and is now deeply unconscious. He is on “life support” but the neurosurgeons have seen him and believe that he has a very grim prognosis. He is expected to die quite quickly and it is felt that there is no treatment that will alter the outcome.

You will be meeting the senior doctor who will explain the situation to you. It is expected that you will be very upset as Mr Jones was completely well until this morning. He has had no warning symptoms at all.

For the examiner

You are to observe the interaction between the candidate and Mrs Jones.
You should not prompt the candidate unless they are failing to do the expected task. Then you should prompt them to re-read the task sheet.

Domains Assessment Objectives

Medical Expertise
Demonstrate understanding of the futility of treatment in this situation

Prioritisation And Decision Making
Understand that no interventions are warranted and that Mr Jones should be “kept comfortable”

Should explain to the wife in a clear caring compassionate way thet her husband is going to die and that there is nothing that can be offered to prevent this. Explain that he is currently on “life support” but that this will in no way alter the final outcome.

The candidate should invite the wife to come in to see Mr Jones but should explain to her that he will be on a breathing machine with IV lines, cather, monitors etc.

If Mrs Jones asks can he be kept in ICU until the family arrive explain that this is unlikely to be possible as despite ICU he is likely to die quite quickly anyway.

Health Advocacy
Should not put the onus of the decision making on the wife, but rather should explain that the outcome has been determined by the severity of the condition. May explore the option of organ donation if brought up by the wife

Should act in a professional manner during the discussion.

Other Assessment Notes

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is 55yo considered Elderly? :O

Edward Tan at 21:48 11 Jun 2017