Code Stroke! Let's talk about... OSCE by Michael

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

Scenario:

You are the consultant on in a tertiary emergency department. You are asked by an RMO to discuss the option of thrombolysis to a 76yo man who has presented with a stroke resulting in right-sided hemiplegia. He fulfils criteria for your local Code Stroke protocol, and is within the time window. He has no speech deficit or receptive dysphasia.

He is aware of the diagnosis and that you are coming to discuss this treatment option.

Instructions for the candidate

You are to discuss the option of thrombolysis with this man as part of the process of gaining informed consent.

Domains being examined

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

For the actor

You are previously fit and well, independent. You live with your wife and have many offspring. You are well educated, now retired professional.
You have no contraindications to thrombolysis.

You have heard of this 'clot-busting' medication after a show on ABC, and believe that it is likely to cure your stroke. You are unaware of the potential side effects. You value your independence and strongly do not wish to 'be a vegetable'.

For the examiner

No instructions.

Domains Assessment Objectives

Medical Expertise
Demonstrate in-depth knowledge of thrombolysis treatment and a good understanding of the evidence available.

Communication
Establish rapport.
Clearly articulate the process of thrombolysis, the evidence and the pros and cons.

Health Advocacy
Discuss the role of thrombolysis in stroke.

Other Assessment Notes

- Indications
- Contraindications (previous CVA, haemorrhage, anticoagulation, hypertension)
- Process (drug, dose, administration = alteplase 0.9mg/kg, 10% as bolus, rest over 2 hours)
- Post thrombolysis care
- Outline potential benefits and evidence from trials (NINDS trial NNT 8 for benefit under 3 hours, ECASS-III NNT 15 for benefit 3-4.5 hours)
- Outline potential harm (ICH NNH up to 20, increased mortality in small strokes (IST-3 data))
- Highlight conflicting studies and controversy about quality of evidence
- Alternative therapies (stroke unit care)


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