COPD exacerbation at community festival

Patient Information

Dispatch: You are called to a 58YO 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 — 58yr (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

Treatment Response

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 'Administer salbutamol via MDI and spacer — please set up the MDI and spacer now.')
! (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. Confirm 6 medication rights: right patient, right drug, right dose, right route, right time, right documentation.
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 Salbutamol (Ventolin) via MDI and spacer — 4–12 inhalations (400–1200 microg) via Space Chamber. Confirm 6 medication rights: right patient, right drug, right dose, right route, right time, right documentation.
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 urgent ambulance support via CSP — IMISTAMBO handover to CSP.
12 Arrange transport to hospital via ambulance — advise CSP of COPD exacerbation with prior salbutamol use and current clinical status.
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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