Explain a sudden cardiac arrest to an adolescent and his mother — OSCE

Candidate instructions

You are the paediatric registrar. You have ten minutes to speak with Liam, a fifteen-year-old boy, and his mother Mrs Chen. Yesterday, Liam collapsed during a school football match and was found to be in ventricular fibrillation. He was resuscitated by bystander CPR and two shocks from the automated external defibrillator at the sports ground. The echocardiogram this morning shows hypertrophic cardiomyopathy — the heart muscle is abnormally thickened, particularly in the wall between the two ventricles. The cardiology team is planning to implant a cardioverter defibrillator (ICD) within the next few days. Liam is frightened and quiet, and his mother is distressed and tearful. Liam's father died suddenly at thirty-eight. Explain what happened yesterday, what the diagnosis means, what the device does and why it is needed, what the implications are for his siblings and for sport, and agree a plan for the coming days. Answer their questions honestly and at a level Liam can engage with. [1]

Actor brief (mother — Mrs Chen)

You are terrified and barely sleeping. You watched your son collapse on the field and you thought he was dead. You have been told his heart is abnormal and that he needs a device implanted. Your husband — Liam's father — died suddenly at thirty-eight, and you never knew why. Now you are being told it was probably the same condition, and you are terrified for your two younger children (ages eight and eleven). You want to know: (1) What happened yesterday — how did his heart stop, and how close did he come to dying? (2) What is hypertrophic cardiomyopathy, and is it genetic — could your other children have it, and could you have it? (3) What is this device they want to put in, and is it safe — will it hurt him, and will it go off? (4) Will he ever play football again — sport is his life? (5) Is this the same thing that killed his father, and could you have prevented this? Push back if the candidate uses jargon, dismisses your fear, or talks only to you and not to Liam. You calm when you feel heard and when the plan is clear. [1] [2]

Actor brief (adolescent — Liam)

You are fifteen and frightened. You love football — it is the most important thing in your life — and now you are being told your heart is abnormal and you might not play again. You are quiet because you do not want to cry in front of your mother. You want to know: (1) Will this happen again? (2) What does the device feel like — will I be different from other kids? (3) Can I still go to school, hang out with my friends, play anything? (4) Will people be able to see it? Engage with a candidate who speaks to you directly, not just to your mother. [2]

Exemplar candidate approach

Open, acknowledge, and include both. "Mrs Chen, Liam, please sit down. I can see how frightening yesterday was — for both of you. You nearly lost Liam, and you are still in shock. I want to explain clearly what happened, what we found, what the plan is, and to answer every question you have. Liam, I am going to talk to you as much as to your mum, because this is your body and your life, and you deserve to understand it." [1]

Explain what happened, honestly. "Yesterday, while Liam was running, his heart went into a chaotic, very fast rhythm called ventricular fibrillation — the electrical signals became disorganised and the heart stopped pumping effectively, so the blood stopped reaching his brain and he collapsed. If nothing had been done, that would have been fatal. The reason he is alive is the bystander CPR and the defibrillator at the sports ground — that machine delivered an electric shock that reset the heart's rhythm within minutes. I want to be honest: yes, he came very close to dying. The single most important thing was that the defibrillator was there and someone used it immediately." [1] [2]

Explain the diagnosis in plain language. "We did an ultrasound of Liam's heart this morning, and we found that the heart muscle is thicker than it should be, especially in the wall between the two main pumping chambers. This condition is called hypertrophic cardiomyopathy — it is a genetic condition that someone is born with, and the thickened muscle can sometimes trigger those dangerous fast rhythms, especially during exercise. It is not caused by anything Liam did, and it is not anyone's fault. It has been there since birth, but it often causes no symptoms until something like this happens." [1]

Address the family implications honestly. "Mrs Chen, you asked about the family, and this is important. Hypertrophic cardiomyopathy runs in families — it is passed down, so if one person has it, each of their children has a fifty-fifty chance. Because Liam's father died suddenly at thirty-eight, it is very likely he had the same condition, and that is what caused his death — we did not know then, but the pattern fits. What this means is that your two younger children, and you yourself, need to be checked — with a heart tracing, an ultrasound, and possibly a genetic blood test. We will organise that through our cardiac genetics team. The important thing is that we can now find out who carries it and who does not, and protect everyone who needs it. This is why identifying the condition matters so much." [1] [2]

Explain the device, age-appropriately. "Liam, the team wants to put in a small device called a defibrillator — an ICD. It sits under the skin, just below your collarbone, and it is about the size of a small matchbox. Most of the time you will not notice it — it sits there monitoring your heartbeat, like a tiny guardian. If your heart ever goes into that dangerous fast rhythm again, the device detects it within seconds and delivers a small shock from inside, to reset the rhythm — the same thing the machine on the football field did, but from inside, and much faster. It means that even if it did happen again, the device would deal with it. You would feel the shock, and it is unpleasant, but it is life-saving, and most people who have these devices never have to use them. Yes, people might be able to feel a small bump under your skin if they look closely, but most of the time no one notices. It will not stop you going to school, hanging out with your friends, or living a full life." [2] [4]

Address sport honestly and with empathy. "Liam, I know football is your life, and I am not going to pretend this is easy. The honest answer is that competitive, high-intensity sport like football is not safe for someone with this condition, even with the device, because the strain on the heart during intense exertion is what triggers the dangerous rhythm. I know that is devastating to hear. What I can tell you is that there are many sports and activities that are safe — things that are not competitive endurance or sprint events — and our team will work with you to find what you can do. I would also like to connect you with other young people who have this condition, because they have been through exactly this, and they are living full, active lives. This is not the end of your life in sport — it is a change in direction." [2]

Address the guilt. "Mrs Chen, you asked whether this is the same thing that killed his father, and whether you could have prevented it. The honest answer is that it almost certainly is the same condition, and that your husband's death was likely caused by it — but no one knew, because the condition was not identified in the family then. You could not have known, and you could not have prevented it. What has changed now is that we know, and that knowledge is what will protect Liam and your other children. The defibrillator on that field, and the CPR, saved Liam's life — and the device we are putting in will keep him safe going forward. You did the right thing, every step of the way." [1]

Check understanding and agree a plan. "Can I check — Liam, what is your biggest worry right now? Mrs Chen, what about you? Here is the plan: Liam stays in hospital for monitoring; the cardiology team implants the device in the next few days; we organise the cardiac genetics referral for the whole family; and our team supports you through the recovery, the return to school, and the sport conversation. You can call me or the team at any time. Is there anything else you want to ask?" [2] [4]

Mark scheme (10 marks)

• Empathy, honesty, and inclusion of the adolescent (2): acknowledges terror and guilt, addresses Liam directly as well as the mother, plain language, does not dismiss the fear. [1]
• Explains the cardiac arrest and the diagnosis clearly (2): ventricular fibrillation, the role of CPR and the defibrillator, the thickened heart muscle of hypertrophic cardiomyopathy, without frightening unnecessarily. [1] [2]
• Addresses the family implications (2): autosomal dominant, fifty-fifty chance, the likely link to the father's death, the need to screen siblings and mother, the role of the cardiac genetics team. [1]
• Explains the device and the sport restriction with empathy (2): what the ICD does, that it is a guardian not a punishment, that sport must change but life goes on, with honest acknowledgment of the grief. [2] [4]
• Checks understanding and agrees a plan (2): invites questions from both, checks comprehension, sets out the next steps and ongoing availability. [2]