((If the trainee does not position the patient supine within the first 2 minutes, the patient's GCS drops to 12 and he becomes less responsive — facilitator states: 'Don's eyes are closing and he's becoming harder to rouse'))

((If oxygen is not applied within 3 minutes, SpO2 drops to 89% on room air and respiratory distress increases to Moderate))

((If the trainee does not take a medication history and misses the Metoprolol, facilitator prompts: 'Don's wife arrives and mentions he takes a tablet for his heart rate every morning — she has the Webster-pak in her bag'))

((If the trainee attempts to sit the patient upright or allow him to stand, the patient becomes dizzy and near-syncopal again — facilitator states: 'Don grabs your arm and says everything has gone grey'))

((If the trainee does not identify this as time critical and does not request ambulance within 5 minutes, the patient's pulse drops to 32 and his GCS drops to 13))

This patient is suffering from unstable bradycardia with adverse signs including symptomatic hypotension (SBP 82 mmHg), near-syncope with transient loss of consciousness, diaphoresis, and altered conscious state — likely exacerbated by his beta-blocker (Metoprolol) use and prolonged exertion in the heat.

• Ensure scene safety and don appropriate PPE.
• Perform Primary Survey — confirm patent airway, assess breathing and circulation, identify slow/weak pulse as immediate priority.
• Position patient supine immediately to address symptomatic hypotension and near-syncope — do NOT allow patient to remain sitting upright or attempt to stand.
• Apply oxygen via Non-Rebreather Mask (NRB) at 10–15 L/min targeting SpO2 94–98%.
• Perform Vital Sign Survey — record BP (noting SBP <90 mmHg), pulse rate (noting bradycardia <60 bpm), SpO2, RR, GCS, BGL, temperature.
• Perform Blood Glucose Level (BGL) test — result 5.8 mmol/L, no hypoglycaemia treatment required.
• Obtain IMISTAMBO history — specifically identify Metoprolol use (beta-blocker) as a contributing factor to bradycardia, prior 'funny heart episode', and penicillin allergy.
• Recognise adverse signs of unstable bradycardia: SBP 82 mmHg (hypotension), near-syncope, diaphoresis, and altered conscious state — this patient is TIME CRITICAL.
• Request ambulance (Priority 1) immediately via State Operations Centre — unstable bradycardia with adverse signs is beyond EHS Primary Care treatment scope; notify of pre-alert.
• Perform reassurance continuously — maintain calm communication with the patient and explain all actions.
• Limit patient exertion entirely — do not allow patient to walk, change position independently, or exert himself.
• Perform Secondary Survey as time permits — assess for distracting injuries or other contributing causes.
• Perform ongoing vital signs monitoring every 5 minutes given time-critical status, noting any improvement or deterioration in GCS, BP, and pulse rate.
• Maintain supine position with legs slightly elevated if tolerated and if no contraindications (no TBI, no respiratory compromise at rest) to support venous return.
• Prepare for possible deterioration to cardiac arrest — ensure AED is immediately accessible and CPR equipment is ready.
• Perform IMISTAMBO handover to ambulance crew, including: medication history (Metoprolol), prior cardiac history, adverse signs on arrival (SBP 82, HR 38, near-syncope), interventions performed, and trending vitals.
• Scenario ends on arrival of ambulance and IMISTAMBO handover.
• Attention to hand hygiene will be given throughout the scenario.

Clinical references: Cardiac Dysrhythmia · Transient Loss of Consciousness (Fainting / Syncope) · Chest Pain / Acute Coronary Syndrome · Primary Survey · Oxygen Delivery · Blood Glucose Monitor · Blood Pressure · Pulse & Respirations