Scenario — COPD exacerbation at community festival

intermediate Respiratory · Adult · 35yr · female

Patient Information

Dispatch	You are called to a 35YO female (Karen Elliot) who has presented to the FAP with increasing shortness of breath and wheeze. She states she has been struggling for the last 20 minutes.
Patient	Karen Elliot — 35yr (65kg)
Incident History	Pt was attending the Fremantle Street Festival when she began to feel increasingly short of breath. Pt states she has a history of COPD and ran out of her usual inhalers two days ago.
Emergency Contact	Michael Elliot (Husband) — 0412 774 381

Initial Rapid Assessment

Response	Alert
Airway	Patent. Nil airway obstruction. Nil stridor. Nil audible secretions.
Breathing	Increased work of breathing. Audible wheeze bilaterally. Speaking in short sentences only. RR elevated. Accessory muscle use noted.
Circulation	Radial pulse present, regular, slightly elevated. Skin warm and dry. Nil peripheral cyanosis. Central perfusion intact.
Disability	GCS 15 (E4V5M6). Alert and orientated to time, place and person. Anxious.
Exposure	Nil rashes, wounds or swelling noted. Pt is dressed appropriately for the weather. Nil tripod positioning but sitting forward in chair.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	88% (RA)	Moderate	24	102	138/88	<2s	15	4 4 ++	37.1	–	2
10 mins	91% (O2 NC 2L/min)	Mild	19	94	132/84	<2s	15	4 4 ++	37.1	–	1

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from an acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD), precipitated by two days without her usual bronchodilator and anticholinergic inhalers, worsened by physical activity and environmental conditions at the festival.

Facilitator Triggers — if trainees miss a critical step

! (If oxygen is applied at high flow via non-rebreather mask without titration — patient's SpO2 climbs to 98% and after 5 minutes she becomes increasingly drowsy, RR drops to 14, GCS drops to 13. Facilitator states: 'Karen seems to be getting sleepier and less responsive.')
! (If the trainee does not position the patient upright or in a position of comfort — patient states 'I really need to sit up, it's much harder to breathe like this.')
! (If vital signs are not repeated at 10 minutes — facilitator prompts: 'Karen asks you if she is getting any better. What are your current observations?')
! (If the trainee attempts to administer salbutamol without noting it is outside EHS Primary Care scope — facilitator states: 'What is your authorisation to administer this medication at your care level?' Remind trainee that salbutamol administration is Intermediate Care and above per the COPD CPG, and EHS Primary Care scope is limited to oxygen titration, positioning, and patient monitoring for this presentation.)

Treatment Objectives

1. Ensure scene safety and don appropriate PPE.
2. Perform Primary Survey — confirm patent airway, assess work of breathing, assess circulation.
3. Position patient upright or in a position of comfort to optimise respiratory mechanics.
4. Perform Vital Sign Survey — record RR, SpO2 (room air), BP, HR, GCS, and temperature.
5. Identify COPD history and absence of inhalers from history taking.
6. Apply oxygen therapy — commence via nasal cannula at 1–2 litres per minute. Titrate carefully to achieve target SpO2 of 88–92%. Do NOT administer high-flow oxygen via non-rebreather mask without monitoring SpO2 closely — risk of hypercapnic drive suppression.
7. Reassess SpO2 after 2–3 minutes of oxygen therapy and adjust flow rate as needed to maintain SpO2 88–92%.
8. Do NOT administer salbutamol — salbutamol administration is outside EHS Primary Care scope for COPD exacerbations per the COPD CPG. Document this and communicate to incoming ambulance crew.
9. Record full observations every 10 minutes and monitor for deterioration.
10. Contact State Operations Centre (SOC) / Clinical Support Paramedic (CSP) for advice if patient deteriorates or does not improve with oxygen titration.
11. Request ambulance via SOC for Advanced Care response — patient requires salbutamol administration and further assessment.
12. Reassure patient continuously throughout the encounter.
13. Perform IMISTAMBO handover to incoming ambulance crew, including COPD diagnosis, current SpO2 on titrated oxygen, oxygen flow rate and mask type, absence of inhalers for 2 days, and clinical observations trend.
14. Scenario ends on arrival of ambulance and IMISTAMBO handover.
15. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Chronic Obstructive Pulmonary Disease (COPD) — Acute Exacerbation · Oxygen · Oxygen Delivery · Pulse Oximetry · Primary Survey · Dyspnoea & Respiratory Distress

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Signs/Symptoms	Increasing shortness of breath, audible wheeze, chest tightness. Productive cough with increased sputum over the past two days.
Allergies	Nil known drug allergies.
Medications	Salbutamol MDI (ran out 2 days ago). Tiotropium inhaler (ran out 2 days ago). No other regular medications.
Pertinent History	Known COPD — diagnosed 4 years ago. Ex-smoker (10 pack-year history, quit 3 years ago). No previous intubations. No recent hospital admissions for COPD.
Last Oral Intake	Ate lunch approximately 1 hour ago. Drinking water throughout the day.
Events Leading	Pt was walking between market stalls at the Fremantle Street Festival. The warm ambient temperature and activity level triggered progressive worsening of her breathing.
Treatment Prior	Nil. Ran out of both inhalers two days ago and has not sought replacement.

Onset	Worsening over the past two days since running out of inhalers. Acutely worse over the last 20 minutes at the festival.
Pain	Mild chest tightness rated 2/10. Non-cardiac in character — associated with breathing effort.
Quality	Tight, wheeze, increased effort to breathe.
Radiates	Nil radiation.
Severity	2/10 chest tightness. Shortness of breath significant — speaking in short sentences.