48 Hours in the Hallway
4m 42s encounter
This is an unedited encounter from ClinicalSim. Review the same recording, transcript, and feedback report the learner received.
The scenario
Your role
You are an emergency department nurse starting your shift. You have just taken report on Mr. Frank Miller, 78 yo M, who has been boarding in a hallway bed for 48 hours. You have not met him before.
Character interaction: Tiffany Miller, Mr. Miller’s adult daughter, stops you in the hallway at the start of your shift.
Timeline: 7 a.m. Mr. Miller arrived in the ED 48 hours ago.
Reason for the conversation: Tiffany has been at his bedside overnight and wants to know what is happening.
Sign-out you received.
Mr. Frank Miller, 78. Admitted 48 h ago with choledocholithiasis: 2 days of RUQ/epigastric pain, longer than his usual short colicky episodes, with nausea, dark urine, light stools; daughter noticed his eyes turning yellow. No prior abdominal surgery. US: CBD 9 mm with a distal stone. Repeat labs this morning are stable, no sign of cholangitis or pancreatitis. His vitals are stable and he has been afebrile. His pain is well controlled on IV meds. IV fluids are running. He has been NPO since midnight for an ERCP today he was bumped yesterday by urgent cases and is on today’s add-on list; there is no time yet. He is still waiting on an inpatient bed. And his Daughter, Tiffany, has been at his bedside.
Objectives
- Respond to a family member’s emotions with empathy.
- Maintain or build trust with a family member.
- Support the patient and family during a prolonged wait for care.
Listen to the recording
Hear the full 4m 42s encounter
▶Transcript23
Excuse me. Are you his nurse now?
Hi, Tiffany. Um, I am his nurse right now, and I'm really sorry that it's been such a long night.
Two days. We've been here two days. Nobody can tell me anything.
Are you going to tell me the same thing everyone else did, that he's "on the list"?
Well, unfortunately, and I, I understand why you feel so frustrated by this, that, that is what I have to share with you right now.
So that's it? "On the list." What does that even mean? They told me that at midnight. They told me that at four.
He hasn't eaten since the night before yesterday. He's seventy-eight years old, in a hallway.
I know. If I could do anything, I really would be. And, and I want you to know that I'm really advocating to make sure that he, um, is highest on the list, even though there is still a list.
Okay. So who's ahead of him? And why?
Yesterday he fasted all day, and then late in the afternoon they just... cancelled. Nobody really explained. Is he going to get worse while he's waiting?
I read last night that a blocked bile duct can get infected.
So everything, um, is being monitored as closely as we possibly can. And so if he ends up developing any signs or symptoms with an, uh, as an infection, then we would absolutely know it.
Okay. That... actually helps to hear. So right now, he's okay?
Like, his bloodwork, or whatever you check, that's... okay this morning?
Um, so I have to be honest with you in that I haven't sat in front of the computer yet. I just got handoff, and so as soon as I look in front of the computer and look at his labs, I will come back and share with you exactly what I know.
Okay. Thank you for being straight with me. When?
Because I've been told "soon" a lot. Can you give me a real time? And can I...
Yeah. That's fair. Um, I'm sorry you've been told "soon" so much and it's been nothing but later and later.
Um, I can share with you that as soon as we're done with this conversation, I'll head over to the nursing station and make sure, um, that I have all the labs and have everything prepared to be able to address with you.
Okay. So... fifteen, twenty minutes? And then you'll come find me?
I'm sorry. I don't mean to be... it's just, I asked for the doctor in charge overnight, and a young doctor came, and then another nurse, and they both said the same thing. I just need somebody to actually know.
Yeah, absolutely. I promise, as soon as I know something, you'll know something. And, and I'm happy to bring over the charge nurse, um, again, and the attending physician if you feel like that would be supportive.
Yeah. Yeah, I'd like that. Somebody who can actually tell me what the plan is.
And... can you ask them about him eating? Or at least, I don't know, something? He's hungry, he's miserable, he barely slept.
The lights, the noise, people walking by with the... you know, for the urinal, there's no privacy.
Yeah. I, I hear the frustration and I, I see it, and I'm really sorry this has been the experience you guys have had so far.
Thank you. It's just me and him. My mom passed four years ago.
He lives alone, he's independent, he's... he's a tough guy. But he looks small in that stretcher. I don't even know if I should go to work today or stay.
You know, I know that you care a lot about your dad, and I want you to feel comfortable leaving him here if you feel like you need to be at work. Um, and I, I just have to say, like, you know, you're the only one that knows what feels right or wrong for you. Um, and if you decide to leave, he'll be in good hands.
Okay. Maybe... maybe I'll wait until you come back with the labs and whoever can talk to me, and then I'll decide. Is that okay?
Absolutely. So, so what I'm hearing from you is that as soon as I leave here, I'm gonna sit down, make sure I have all the labs and some answers for you that I can. I'm gonna come back here to deliver them for you, and then I'll let the charge nurse and attending physician know that you're hoping to speak with them.
Yes. That's exactly it. Thank you.
Really. Just... please don't forget about him. I know you're busy, I know it's shift change, but... he's been here two days.
I know. I know. You're doing incredible, um, and I promise that I will take good care of him.
Okay. Thank you. I'll be right here.
Feedback
How to read this feedback
Every score is written as value / max, so you can see both the points earned and the points available. A spoken simulation can’t surface everything a real visit would, so when something couldn’t be judged fairly, the feedback labels it instead of holding it against you. Here’s what each label means.
(simulation limitation)The voice/text modality physically can't reveal it
e.g. eye contact, body language, facial affect, physical exam, EHR documentation
(no opportunity)The scenario never created the occasion
e.g. conversation ended before this step; situation never arose
(not applicable)Out of scope for this case
e.g. a domain that doesn't apply here
A not assessable item does not affect the score. The format did not give you a fair chance to show that behavior, so the item is excluded. That is different from “Not demonstrated,” where the moment was there and the skill didn’t come through. Only the second one reflects on how the encounter went.
For competency frameworks with levels, some scenarios can only assess a competency up to a certain level because the higher levels turn on behaviors a single spoken encounter can’t surface. When a scenario’s ceiling is below Level 4, that milestone is still shown for its formative value but is “Not in overall grade” . It doesn’t count toward the overall grade, so a case that can’t fully exercise a competency never reads as a shortfall.
“I understand why you feel so frustrated by this”
Learner said: "I understand why you feel so frustrated by this" — naming the frustration directly, and again when the daughter catalogued the hallway indignities Learner said: "I hear the frustration and I, I see it", landed accurately and tentatively, and she responded with thanks rather than escalating. Keep pairing these accurate names with a pause for her to say more.
“I'm sorry you've been told soon so much and it's been nothing but later and later”
Learner said: "I'm sorry you've been told "soon" so much and it's been nothing but later and later" — legitimized her experience of being told the same vague word repeatedly without claiming to fully grasp it, and because it came right before a concrete commitment it read as genuine. Keep placing this acknowledgement before the plan, not instead of it.
“I know that you care a lot about your dad”
Learner said: "I know that you care a lot about your dad" — named her caring and her role as her father's one advocate, which landed when she disclosed she was alone in this, though the praise phrasing Learner said: "You're doing incredible" risked sounding generic for a daughter who wanted competent care more than applause. Keep tying recognition to the specific effort you can see.
“I promise, as soon as I know something, you'll know something”
Learner said: "I promise, as soon as I know something, you'll know something ... I'm happy to bring over the charge nurse" — repeated, specific commitments to check the labs and return and to bring the charge nurse and attending directly answered her fear of being abandoned in the system, and she visibly settled. Keep these concrete commitments; just pair one with an exploring question.
No corresponding moment in the encounter was taken up — when she voiced ambivalence about staying or going the reply moved to reassurance instead of curiosity. A stronger move is "It sounds like seeing him like that is really hard — can you say more about what's going through your mind right now?" (suggested wording).
No moment in this encounter — the softer disclosures about whether to stay and how small her father looked on the stretcher were met with reassurance and logistics rather than exploration; a stronger move is "It sounds like seeing him like that is really hard — can you say more about what's going through your mind right now?" (suggested wording).
Missed moments
Two emotional cues got answered with reassurance or logistics rather than exploration.
When she wondered aloud whether to stay or go — Character said: "I don't even know if I should go to work today or stay" — the reply told her she was the only one who knew what felt right and that he would be in good hands. That is kind, but it closes the question rather than opening it; she was asking to be helped to think, not to be reassured.
When she said the quieter, heavier thing — Character said: "But he looks small in that stretcher" — the grief and fear underneath went unexplored. The conversation stayed on the plan. A moment to sit with that image would have met the person rather than the task.
Otherwise, the frustration cues throughout were consistently met, which is the strength of this encounter.
Overall impression
- Strengths — Supporting was handled with real skill: concrete, repeated, specific commitments that directly answered the daughter's fear of being forgotten in the system, capped by a clear read-back of exactly what she would do next. Naming and Understanding were accurate and tentative, and the honesty about not yet having seen the labs built trust rather than eroding it.
- Priority gaps — The softer, more vulnerable disclosures — her ambivalence about whether to stay, and how small her father looked on the stretcher — were met with reassurance instead of curiosity. These were the moments the daughter risked something personal, and they were the moments the conversation moved on from fastest.
- Top action items
- When someone voices ambivalence like whether to stay or go, ask before you reassure — draw out what they are weighing rather than resolving it for them.
- When a person says something tender and off-plan, pause on it before returning to logistics. Suggested wording: "It sounds like seeing him like that is really hard — can you say more about what's going through your mind right now?"
- Keep the specific, repeated commitments — they were the most effective thing you did; just pair one of them with an exploring question.
Formative use only. This feedback is AI-generated for education and professional development. It is not a clinical judgment or a credentialing determination, and must not be used as the sole basis for any promotion, remediation, credentialing, or other consequential decision. Responsibility for evaluation and personnel decisions stays with the program and its faculty.
References
Patient. 78-year-old man admitted with choledocholithiasis. Two days of RUQ/epigastric pain, more prolonged than his prior self-limited colicky episodes, with nausea, dark urine and lighter stools; scleral icterus noticed by his daughter. No prior abdominal surgery. Exam: vital signs normal, scleral icterus, mild RUQ tenderness, negative Murphy’s sign, no peritonitis, oriented. Ultrasound: cholelithiasis; CBD dilated to 9 mm; echogenic focus with acoustic shadowing in the distal CBD; no gallbladder wall thickening or pericholecystic fluid.
Supporting labs (case background; not given to the learner).
| Admission (48 h ago) | Repeat, just before sign-out | |
|---|---|---|
| Total bilirubin (0.2 to 1.2 mg/dL) | 4.8 | 4.6 |
| Direct bilirubin (0 to 0.3 mg/dL) | 3.6 | 3.5 |
| Alkaline phosphatase (40 to 130 U/L) | 275 | 268 |
| GGT (8 to 61 U/L) | 450 | 442 |
| ALT (7 to 56 U/L) | 168 | 160 |
| AST (10 to 40 U/L) | 152 | 141 |
| Lipase (13 to 60 U/L) | 41 | 38 |
| WBC (4.5 to 11 x10^3/uL) | 8.4 | 7.9 |
Vital signs: T 37.0 C, HR 78, BP 138/76, RR 16, SpO2 97% on room air. Afebrile throughout; hemodynamically stable; pain well controlled.
Key clinical facts.
- Mr. Miller meets ASGE high-probability predictors (CBD stone on ultrasound; total bilirubin >4 mg/dL with CBD dilated >6 mm); the recommended strategy is to proceed to ERCP. [ASGE 2019, Table 15]
- Urgent ERCP (within 48 hours) benefits patients with cholangitis; the guideline sets no time window for choledocholithiasis without cholangitis. [ASGE 2019]
- He does not have cholangitis or pancreatitis: afebrile, normal WBC, hemodynamically stable, normal lipase, stable cholestatic labs. [Case data]
- While he waits, the team monitors him for signs of infection. [Case data]
- Premature reassurance and blocking are communication behaviors to avoid. [Back 2005, p. 165]
References.
- Buxbaum JL, Abbas Fehmi SM, Sultan S, et al. ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis. Gastrointest Endosc. 2019;89(6):1075-1105.e15. doi:10.1016/j.gie.2018.10.001
- Back AL, Arnold RM, Baile WF, Tulsky JA, Fryer-Edwards K. Approaching difficult communication tasks in oncology. CA Cancer J Clin. 2005;55(3):164-177. doi:10.3322/canjclin.55.3.164
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