Scenario — COPD exacerbation at community festival

intermediate Respiratory · Adult · 35yr · male

Patient Information

Dispatch	You are called to a 35YO male (Derek Haines) who has walked into the FAP at the Fremantle Winter Festival complaining of increasing shortness of breath and wheezing. Bystanders report he has been struggling for the last 20 minutes.
Patient	Derek Haines — 35yr (80kg)
Incident History	Pt states his breathing has been getting progressively worse over the past 20 minutes. He reports a known history of COPD and says today is worse than usual. He has been walking around the festival grounds in the cool morning air.
Emergency Contact	Sandra Haines (Wife) — 0421 847 293

Initial Rapid Assessment

Response	Alert
Airway	Patent. Nil airway obstruction. Nil stridor. Speaking in short sentences only.
Breathing	DETECT & CORRECT — Increased respiratory effort, accessory muscle use visible, audible wheeze bilaterally, RR 26/min. SpO2 85% on room air.
Circulation	Radial pulse present, rapid and slightly weak. Skin pale, mild diaphoresis. Nil external bleeding.
Disability	GCS 15 (E4V5M6). Orientated to time, place and person. Mildly anxious.
Exposure	Nil rashes, no visible trauma. Wearing a medical alert bracelet indicating COPD. Cool ambient temperature at outdoor festival.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	85% (RA)	Moderate	26	112	138/88	<2s	15	4 4 ++	36.7	–	2
10 mins	91% (O2 NC 2L/min)	Mild	20	98	132/84	<2s	15	4 4 ++	36.7	–	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 cold air exposure and a likely infective exacerbation given 2 days of increased sputum production.

Facilitator Triggers — if trainees miss a critical step

! (If oxygen is administered at high flow — e.g. NRB 15L/min — without titration: patient becomes drowsy after 5 minutes, GCS drops to 13 (E3V4M6), RR decreases to 10/min — facilitator prompts 'The patient looks sleepy and is breathing more slowly — what do you want to do about their oxygen?')
! (If SpO2 target is not titrated to 88–92% and high-flow oxygen is continued: patient begins to look increasingly lethargic at 10 minutes and respiratory rate falls to 8/min — facilitator states 'The patient is now barely breathing — what is your next action?')
! (If the trainee does not position the patient upright: patient states 'I can't breathe like this, I need to sit up' — facilitator prompts 'The patient is clearly more distressed in their current position.')
! (If the trainee attempts to administer salbutamol via nebuliser: facilitator reminds 'EHS are not authorised to administer nebulised medications — what alternative route is available to you?')
! (If the trainee does not ask about medications and misses that the patient has already used his own Ventolin three times: facilitator prompts 'You notice a Ventolin puffer in the patient's shirt pocket — do you want to ask him about it?')

Treatment Objectives

1. Ensure personal safety and don appropriate PPE including gloves.
2. Conduct Primary Survey — confirm patent airway, identify moderate respiratory distress, detect SpO2 85% on room air.
3. Position patient upright or in position of comfort immediately — do not lay the patient flat.
4. Apply pulse oximetry monitoring and conduct Vital Sign Survey.
5. Administer oxygen via nasal cannula at 1–2 L/min — titrate carefully to achieve SpO2 target of 88–92% for COPD patient. Do NOT use high-flow oxygen or non-rebreather mask without clinical justification.
6. Reassess SpO2 every 2–3 minutes during oxygen titration — if target not achieved on nasal cannula, cautiously increase flow rate by 1 L/min increments up to a maximum of 4 L/min before considering simple face mask at 5 L/min.
7. Conduct IMISTAMBO-style history: confirm known COPD, 2 days of increased sputum, prior salbutamol use, current medications (Spiriva, Ventolin), nil known drug allergies.
8. Assist patient to administer their own salbutamol (Ventolin) via MDI with spacer — 4–12 inhalations (400–1200 microg) via Space Chamber. Note: EHS may assist patient to use their own inhaler as per CPG.
9. Monitor patient response to oxygen therapy and salbutamol — repeat full vital signs at 10 minutes.
10. Record full observations every 10 minutes (or 5 minutes if patient appears time critical).
11. Recognise time-critical indicators: SpO2 not improving to 88–92% with titrated oxygen, increasing respiratory distress, decreasing GCS — escalate to Priority 1 transport with pre-notification to receiving hospital.
12. Arrange transport to hospital — this patient has not fully responded to prior self-administered bronchodilator and requires advanced care (IV access, formal salbutamol, possible ipratropium).
13. Scenario ends on arrival of ambulance and IMISTAMBO handover.
14. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Chronic Obstructive Pulmonary Disease (COPD) — Acute Exacerbation · Oxygen · Salbutamol Sulphate · MDI & Space Chamber · Pulse Oximetry · Primary Survey

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Signs/Symptoms	Progressive shortness of breath, audible wheeze, productive cough with increased yellow sputum over past 2 days, chest tightness.
Allergies	Nil known drug allergies.
Medications	Tiotropium (Spiriva) inhaler — daily. Salbutamol (Ventolin) puffer — PRN. Has his own Ventolin with him but reports using it three times already today with minimal relief.
Pertinent History	Known COPD diagnosed 4 years ago. Ex-smoker (15 pack years, quit 2 years ago). No known cardiac history. No recent hospital admissions.
Last Oral Intake	Breakfast approximately 2 hours ago. Drinking water throughout the morning.
Events Leading	Patient was walking around the Fremantle Winter Festival grounds in cool outdoor air. Noticed breathing worsening progressively. Came to the FAP when he could no longer walk comfortably between stalls.
Treatment Prior	Self-administered own Ventolin puffer (without spacer) three times over the past 2 hours with only partial and brief relief.

Onset	Gradual worsening over the past 2 days, acutely worse in the last 20 minutes whilst walking around the festival in the cool air.
Pain	Mild chest tightness rated 2/10. Non-radiating. Not cardiac in character.
Quality	Described as 'tight' and 'hard to breathe out'. Worse with exertion.
Radiates	Nil
Severity	2/10 chest tightness. Dyspnoea is the primary complaint — patient rates breathing difficulty as 7/10.