((If suction is not performed within the first 2 minutes: patient produces a large volume of water-tinged sputum, GCS drops to 8, and gurgling becomes louder — prompt trainee to suction and reassess airway immediately.))

((If high-flow oxygen via non-rebreather mask is not applied promptly: SpO2 remains at 82% and patient becomes increasingly agitated and cyanotic — facilitator states 'the patient is reaching for their face and becoming combative'.))

((If wet clothing is not removed and passive rewarming not initiated within 5 minutes: temperature drops to 32.8°C at 10 minutes and pulse becomes more irregular — facilitator states 'patient's shivering has now ceased and his skin is becoming more mottled'.))

((If the trainee attempts to induce vomiting or applies abdominal pressure to 'drain' the lungs: facilitator states 'the patient immediately vomits a large volume — what is your next priority?' — redirect to lateral position and airway management.))

((If hypothermia is identified but BGL is not checked: facilitator prompts 'what other assessment might be relevant in a hypothermic patient with altered conscious state?'))

((If trainee does not consider aspiration of contaminated water as an ongoing risk factor for respiratory deterioration: facilitator prompts 'the patient begins coughing up dark-tinged frothy sputum — does this change anything about your assessment or handover to ambulance?'))

This patient is suffering from immersion (near-drowning) with aspiration of contaminated river water and secondary hypothermia following prolonged submersion. The patient has achieved spontaneous circulation following bystander CPR but remains at high risk of delayed respiratory deterioration, aspiration pneumonitis, and re-arrest due to hypothermia and underlying cardiac history.

• Ensure personal safety — don gloves and appropriate PPE given contaminated river water exposure risk.
• Perform Primary Survey — open and clear airway using lateral position to facilitate drainage of secretions.
• Suction oropharynx using Yankauer catheter to clear water and secretions — maximum 5 seconds per pass, reassess between passes.
• Insert Oropharyngeal Airway (OPA) — size measured from centre of lips to angle of mandible — if patient tolerates and GCS permits.
• Apply high-flow oxygen via Non-Rebreather Mask at 10–15 litres per minute — target SpO2 94–98%.
• Assist ventilations with BVM if respiratory effort deteriorates or becomes inadequate — ventilate gently, avoid high pressures.
• Remove all wet clothing immediately to halt ongoing heat loss — use scissors/trauma shears as required.
• Perform passive rewarming — cover patient with Ready-Heat blanket (sticker side down, over a sheet) then standard blanket — do NOT place directly on skin.
• Treat hypothermia as per CPG: remove from cold environment, dry and cover, warm surroundings.
• Perform Vital Sign Survey — GCS, SpO2, RR, BP, HR, CRT, temperature (tympanic), BGL.
• Perform Secondary/CNS Survey — assess for concealed trauma from fall onto jetty, check all limbs for injury.
• Monitor closely for signs of re-arrest — hypothermia significantly increases risk; have defibrillator immediately available.
• Do NOT attempt to empty stomach by external abdominal pressure — aspiration risk is high.
• Position patient in lateral position if unresponsive or vomiting — left lateral if GCS deteriorates further.
• Record full observations every 5 minutes given time-critical status.
• Note contaminated river water aspiration in handover — risk of delayed aspiration pneumonitis and water-borne organism exposure.
• Notify ambulance and receiving ED of prolonged submersion, hypothermia, aspiration of contaminated water, current GCS, SpO2 trend, and known cardiac history including anticoagulation with warfarin.
• Scenario ends on arrival of ambulance and IMISTAMBO handover.
• Attention to hand hygiene will be given throughout the scenario.

Clinical references: Immersion · Hypothermia · Unconsciousness · Cardiac Arrest - Adult · Oxygen Delivery · Suction · Lateral Position · Oropharyngeal Airway · Bag Valve Mask Ventilation · Ready Heat Blanket · Tympanic Thermometer · Blood Glucose Monitor · Primary Survey · Secondary & CNS Survey